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Emory Health and Rehab

983 N Texas St, Emory, TX 75440 · Government - Hospital district · 68 certified beds · (903) 473-3752 Medicare & Medicaid certified

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Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation
Insights

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

In its favor
  • 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
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (28) — 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 (80%) 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
801 N Waldrip St · (903) 962-7551 · Call to confirm hours
Pharmacy
101 N Texas St · (903) 473-2313 · Call to confirm hours
Grocery
101 N Texas St · (903) 473-7257 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.8%15.8%15.4%typical
Long-stay residents who lose too much weight0.6%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.7%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.7%3.3%3.3%worse
Long-stay residents whose ability to walk worsened26.2%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication28.0%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine92.9%98.0%95.3%typical
Long-stay residents with pressure ulcers2.8%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control14.6%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table7.1%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication2.8%1.5%1.4%worse
Long-stay hospitalizations per 1,000 resident days1.212.171.67better
Long-stay outpatient ER visits per 1,000 resident days1.522.061.80better

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

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

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

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

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

11.2%U.S. median 10.7%
Went back to hospital
0.27U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 36% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot 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 SNF11.2%CMS range 6.2–16.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identifiednot 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot 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 worsenednot 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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.381.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.22
RN hours/ resident / day
0.75
LPN hours/ resident / day
1.87
Aide hours/ resident / day
2.85
Total nurse hours/ resident / day
0.22
RN hoursweekends
80.0%
Total nursing turnover
100.0%
RN turnover

How full it usually is: this home is certified for 68 beds and averages 45.9 residents a day — about 68% occupied, or roughly 22 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 2.85 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.22 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 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 2.70 hrs/resident/day on weekends vs 2.90 on weekdays — 7% thinner on weekends. RN hours go from 0.23 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 80% is well above the national median of 45%. 1 administrator has left in the past year.

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

5
deficiencies at the latest standard inspection (2025-08-05)
11
at the previous standard inspection (2024-07-10)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2023-05-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an environment that was free of accident hazards for 2 of 14 residents (Resident #17 and Resident #184) reviewed for accidents hazards from hot coffee. The facility failed to ensure safety measures were in place after Resident #184 received a second-degree burn (burns that involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful) from hot coffee that required treatment. The facility failed to ensure safety measures were in place to prevent Resident #17 from obtaining an injury from hot coffee. An Immediate Jeopardy (IJ) situation was identified on 05/09/23. The IJ template was provided to the facility on [DATE] at 11:14 a.m., While the IJ was removed on 05/10/23 at 4:14 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility's need to evaluate the effectiveness of the corrective…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 1 of 6 (Resident #19) residents reviewed.The facility failed to update Resident #19's care plans for her fall mat on 04/30/25. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.Findings included: Record review of Resident #19's face sheet, dated 08/05/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), hypertension (high blood pressure), and Osteoarthritis (OA) (a degenerative joint disease that causes cartilage breakdown, leading to pain, stiffness, and reduced mobility in affected joints). Record review of Resident 19's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the environment was free of accidents and hazards for 1 of 6 (Resident #19) residents reviewed for accidents. The facility failed to ensure Resident #19's fall mat was beside her bed on 08/03/25. This failure could place residents at risk for fall related injuries.Findings included: Record review of Resident #19's face sheet, dated 08/05/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), hypertension (high blood pressure), and Osteoarthritis (OA) (a degenerative joint disease that causes cartilage breakdown, leading to pain, stiffness, and reduced mobility in affected joints). Record review of Resident #19's quarterly MDS assessment, dated 05/29/25, indicated Resident #19 was usually understood and was usually understood by others. Resident #19 BIMs score was 01 indicating she was severely…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-05 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 1 medication room reviewed for pharmacy services. The facility failed to ensure the Medication Storage Room did not contain Resident #18's expired ondansetron (nausea medication) with an expiration date of 06/11/25 or an expired Tums bottle with an expiration date of 09/2024. This failure could place the residents at risk of not receiving the intended therapeutic benefits of prescribed medications and medications being used passed their effective or expiration date.Findings included: During an observation and interview on 08/04/25 at 12:26 PM, the medication storage room was reviewed and Resident #18's ondansetron 4mg medication card containing 26 tablets was noted with an expiration date of 06/11/25. A bottle of Tums was also located in the medication storage room that had an expiration date of 09/2024. MA F said she…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-05 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Nurse Cart) observed for medication storage. The facility failed to ensure the Nurse's cart did not contain Resident #2's undated NovoLog insulin bottle. This failure could place residents at risk for not receiving drugs and biologicals as needed and medications being used passed their effective or expiration date.Findings included: During an observation and interview on 08/04/25 at 11:00 AM, the Nurse's Cart was reviewed and a bottle of Resident #2's NovoLog insulin was noted to be opened and undated. LVN E looked at Resident #2's NovoLog insulin bottle and said there was not a date on it. She said the nurse who opened the insulin should have dated it. She said by not dating the insulin when opened the staff would not know if the insulin had gone past the shelf…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 15 residents reviewed for infection control practices (Resident #20). The facility failed to ensure CNA C changed his gloves and performed hand hygiene while providing incontinent care to Resident #20. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: Record review of the undated face sheet indicated Resident #2 was an [AGE] year-old male that admitted [DATE] with diagnoses that included: Dementia (a decline in mental abilities affecting daily life), cerebral infarction (a stroke, death of brain tissue due to lack of blood flow), and muscle wasting and atrophy (loss of muscle mass and strength). Record review of the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-07-10 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were labeled and dated. 2. Hair restraints worn. 3. The microwave was clean and free of food debris. 4. The toaster was clean and free of food debris. 5. Expired food item was discarded. 6. Refrigerator/Freezer log was kept up to date. 7. Personal drinks were kept out of facility refrigerator. These failures could place residents at risk for foodborne illness. Findings included: During an observation and interview on 07/07/2024 at 8:00 a.m., [NAME] C was in the kitchen without wearing a hair restraint. [NAME] C stated the one she had on her head had ripped. [NAME] C stated she was going to get another one but got sidetracked. [NAME] C stated it was important to wear a hairnet while in the kitchen to prevent food contamination. During the initial tour observation and interview with the [NAME] C on 07/07/2024 between 8:21 a.m. and 8:50…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-10 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 4 of 4 resident's (Resident #'s 4, 17, 25, and 34) reviewed for a homelike environment. The facility failed to ensure Resident #25's wall behind her bed was free from deep gouges into the sheetrock measuring 4 inch wide and 2 feet long. The facility failed to ensure Resident #17's and Resident #34's bed linens were changed. The facility failed to ensure Resident #34 had hot water available in the bathroom. The facility failed to ensure Resident #34 had a toilet seat that was free from peeling paint. The facility failed to ensure Resident #34's toilet was flushing properly. The facility failed to ensure Resident #4's hot water in the bathroom sink was not running continuously, and Resident #4 had cold water available. These failures could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: 1. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-10 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, 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 2 of 4 residents (Resident #'s 140 and 17) reviewed for ADLs. The facility failed to ensure Resident #140's face was free from facial hair. The facility failed to ensure Resident #17 received routine scheduled showers. These failures could place residents at risk for not receiving services/care and a decreased quality of life. 1) Record review of a face sheet dated 6/10/2024 indicated Resident #140 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of profound intellectual disabilities (the inability to live alone, and care for themselves). Record review of the admission MDS dated [DATE] indicated Resident #140 was rarely/never understood, and rarely/never understood others. The MDS indicated the BIMS assessment was not conducted. The MDS indicated Resident #140 had severely impaired…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-10 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 staff (Laundry Aides G, H, and K) reviewed for infection control practices on 2 of 4 halls ( halls 1 and 2). The facility failed to ensure that Laundry Aides G , H, and K covered the laundry cart while delivering the resident's clothing. This failure could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: During an observation on 07/07/2024 at 8:17 AM., Laundry Aide K was observed in hall 2 pushing an uncovered laundry cart with clean clothes exposed. During an observation on 07/08/20244 at 9:20 AM., Laundry Aide K was observed in hall 1 pushing an uncovered laundry cart with clean clothes exposed. During an observation on 07/09/2024 at 10:00 AM, Laundry Aide H was observed in hall 2 pushing an uncovered laundry cart with clean clothes exposed. During…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-10 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident's representative and consult the physician immediately when there was a significant change in the resident's physical, mental, or psychosocial status that is, a deterioration of health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 4 residents (Resident #30) reviewed for notification of changes. The facility failed to consult Resident #30's physician and notify the resident representative when Resident #30 refused to have a CMP (complete metabolic panel lab draw to provide information about the body's chemical balance) and a HBA1C (glycated hemoglobin test that measure the average amount of blood sugar) lab drawn on 05/09/24, 05/10/24, and 05/13/24. This failure could place residents' representative/physician at risk of not being aware of any changes in their conditions and could result in delay in treatment and decline in residents' health and well-being. Findings included:…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2024-07-10 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 3 of 31 residents (Resident #17, and Resident #14 and Resident #1) reviewed for comprehensive care plans. The facility failed to ensure Resident #17's care plan indicated he smoked. The facility failed to ensure Resident #14's care plan indicated he wandered. This failure could place residents at risk of not having individual needs met and a decreased quality of life. Findings included: 1. Record review of the face sheet dated 06/28/2024 indicated, Resident #17 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), hyperlipidemia (high levels of fat particles in the blood), history of stroke, benign prostatic hyperplasia (prostate gland enlargement resulting in difficulty with urination)…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided with professional standards of practice for 1 of 3 residents (Resident #7) reviewed for respiratory care and services. The facility failed to properly store Resident #7's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask while not in use. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. Findings include: 1. Record review of Resident #7's order summary report, dated for the month of July 2024, indicated Resident #7 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included diabetes mellitus (a group of diseases that result in too much sugar in the blood), chronic pulmonary edema (excessive fluid in the lungs), essential hypertension (high blood pressure), and atrial fibrillation (irregular, often rapid heart…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-10 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record reviews, the facility failed to ensure correct installation, use and maintenance of bedrails for 1 of 1 resident (Resident #21) reviewed for bedrails. 1.The facility failed to assess Resident #s 21 for the risk of entrapment from bed rails prior to installation. 2. The facility failed to document the attempt of alternatives to meet Resident #21's needs. These failures could place residents at risk for entrapment with serious injury and even death. Findings included: Record review of a face sheet dated 5/17/2024 indicated Resident #21 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnosis of end stage dementia. Record review of the Consolidated Physician's orders dated July 2024 indicated Resident #21 was not ordered a bedrail device. Record review of the Significant Change MDS dated [DATE] indicated Resident #21 was rarely understood, and rarely understands others. The MDS indicated Resident #21's BIMS score was not determined due…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-10 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received therapeutic diets that were prescibed by the attending physician for 1 of 13 residents (Resident #28) reviewed for therapeutic diets. The facility did not ensure Resident #28 was given double protein portion as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings Included: Record review of the face sheet, dated 05/17/2024, indicated Resident #28 was an [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar) Record review of the physician orders dated 02/07/2024, indicated Resident #28 had an order, which started on 02/07/2024, extra portions of meat with meals. Record review of the quarterly MDS assessment, dated 02/20/2024, indicated Resident #28 usually made himself…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-10 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Resident # 21) reviewed for hospice services. The facility failed to obtain Resident #21's most recent updated hospice plan of care. The facility failed to ensure Resident #21's hospice plan of care accurately reflect his medication regimen. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: Record review of a face sheet dated 5/17/2024 indicated Resident #21 was a [AGE] year-old male who admitted on [DATE] and readmitted 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-10 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 1 of 4 residents (Resident #1) reviewed for antibiotic use. The facility failed to ensure Resident #1 had documented appropriate lab work and diagnoses to support the use of prescribed antibiotics. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: Record review of Resident #1's face sheet, dated 06/28/2024, indicated Resident #1 was an [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included multiple sclerosis (chronic, progressive disease involving damage to the sheaths of nerves cells in the brain and spinal cord causing numbness, impairment…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-05-10 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was prepared and served in a manner that prevented foodborne illness for 1 of 1 kitchen reviewed for food preparation and serving. The facility did not ensure hair restraints were worn appropriately by Dietary [NAME] C and [NAME] D while they prepared and served residents' food. This failure could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During an observation on 05/07/23 at 11:49 a.m., [NAME] C was not wearing a hair restraint appropriately while serving the lunch meal. [NAME] C's hair was visible outside of the hairnet at the ears and neck. During an observation on 05/08/23 at 11:23 a.m., [NAME] D was not wearing a hair restraint appropriately while preparing the lunch meal. [NAME] D's hair was visible outside of the hairnet at the base of her neck. During an interview on 05/08/23 at 1:45 p.m., [NAME] D said she wore a hair restraint to cover her hair and to prevent hair from falling into the food. [NAME] D touched her hair by the base of her…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-05-10 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 of 1 nurse's cart and 1 of 2 medication carts (#2 medication cart) reviewed for pharmacy services. The facility failed to ensure the nurse's cart was locked when left unattended in the hallway. The facility failed to ensure all medications on the nurses' cart and the #2 medication cart were labeled when opened. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: 1. During an observation and interview on 05/09/23 at 09:28 AM, the nurse's cart was on the 100 hall and was unlocked. There was no staff present. LVN B came out of a resident's room, and she said she was the one responsible for leaving the cart unlocked. LVN B said it was her responsibility to lock the cart when left unattended. LVN B said by leaving the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-10 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician when there was significant change in the resident's physical, mental, or psychosocial status for 1 of 2 residents (Resident # 17) reviewed for notification of changes. The facility failed to notify the physician for Resident #17 after LVN E assessed redness on his left inner thigh from spilled hot coffee. This failure could place residents at risk of their physicians not being aware of the resident conditions and delay treatments for the residents' conditions. Findings included: Record review of Resident 17's face sheet dated 03/20/20 indicated he was a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnoses including psychotic disorders (severe mental disorders that cause abnormal thinking and perceptions), peripheral vascular disease {PVD} (problem with poor blood flow), arthritis (swelling and tenderness of joints), and Parkinson (a brain disorder that causes…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-10 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 14 residents reviewed for care plans. (Resident #30) The facility failed to develop a care plan for Resident #30's right wrist and hand contractures. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: Record review of a face sheet dated 12/30/2022, indicated Resident #30 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified fracture of upper end of right humerus (break in the lower end of the upper arm), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and unspecified atrial fibrillation (rapid, irregular heart rate). Record review of the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 out of 3 residents reviewed for pressure ulcers. (Resident #20) LVN A failed to change his gloves while providing wound care for Resident #20. This failure could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection. Findings included: Record review of a face sheet dated 04/29/2022, indicated Resident #20 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified sequalae of cerebral infarction (stroke), essential (primary) hypertension (high blood pressure), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 4 residents reviewed for respiratory care (Residents #24). The facility failed to ensure Resident #24 had an oxygen concentrator filter in place. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease. Findings Included: Record review of Resident #24's face sheet dated 01/10/23 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses Alzheimer's Disease (a neurodegenerative disease that slowly and progressively worsens), fracture of right hip, chronic obstructive pulmonary disease (a progressive lung disease with log-term respiratory symptoms and airflow limitations), high blood pressure, and high cholesterol. Record review of Resident #24's most recent quarterly MDS dated [DATE]…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-10 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents reviewed for unnecessary medications. (Resident #26) The facility failed to have an appropriate diagnosis or adequate indication for the use of Resident #26's Seroquel (antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder). This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings include: Record review of Resident #26's face sheet dated 03/02/2023 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnosis of senile degeneration of the brain (mental loss related to aging, dementia), edema…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-10 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 laboratory services were obtained to meet the needs of 1 of 14 residents reviewed for laboratory services (Residents #25). The facility failed to obtain ordered CBC and BMP levels for Resident #25. This failure could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs. Findings included: 1. Record review of Resident #25's face sheet dated 10/11/22, indicated a [AGE] year old male who admitted to the facility on [DATE] with diagnoses which included anemia (a condition in which the body does not have enough healthy red blood cells), congestive heart failure (condition in which the heart does not pump blood as well as it should), cerebral infarction (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), and chronic obstructive pulmonary disease (lung diseases that block airflow and make it difficult to breathe). Record review of Resident #25's…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-10 · tag F0885 — failed to notify residents/families about COVID-19 — isolated
    Report COVID19 data to residents and families.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify residents and/or the residents' Responsible Party (RP) or families by 5:00 p.m. the following day, after 2 of 2 residents (Resident #'s 14 and 84) test positive for Covid-19. The facility failed to inform residents and/or the residents' RPs/family of Resident #'s 14 and 84's confirmed infections of Covid-19 by the 5:00 p.m. on 12/08/2022 and 03/02/2023. This failure could place residents, families, and responsible parties at risk of not being kept informed on the Covid-19 status in the facility. Findings included: 1. Record review of Resident #84 face sheet dated 12/08/2022 indicated she was a [AGE] year-old female who admitted on [DATE] with the diagnosis of heart disease, diabetes, and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath. Record review of a nurse note dated 12/07/2022 at 8:00 a.m., LVN A wrote Resident #84 was sent to the local emergency room with shortness 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-05-10 · tag F0640 — widespread
    Encode 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 ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 2 resident (Resident #3) reviewed for discharge MDS assessments. The facility did not ensure Resident #3's discharge MDS assessment was completed and transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required. Findings included: Record review of a face sheet dated [DATE] indicated, Resident #3 was initially admitted on [DATE], and readmitted on [DATE] with the diagnoses of memory loss and high blood pressure. Record review of a discharge note dated [DATE] indicated Resident #3 expired in the facility. During interview with the ADON/MDS coordinator on [DATE] at 3:30 p.m., she said while reviewing the electronic medical record for Resident #3's MDS submissions the discharge…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-05-10 · tag F0851 — widespread
    Electronically 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 specification established by CMS for 1 of 1 facility reviewed for administration (Fiscal year 2023 for the first quarter October 1, 2022, to December 31, 2022). The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for the 1st quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met. Findings included: Review of the facility's undated staff roster indicated the following: 1 Administrator 3 RN's (included DON) 1 Maintenance person 1 Social Worker 1 Activity Director assistant 11 Licensed vocational nurses (included 1 ADON/MDS Coordinator) 12 CNAs/Medication aide 6 Housekeeping/Laundry Personnel 6 Dietary Personnel (included one Dietary Manager) Record review of the CMS 672 form dated and signed by 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.

    Administration Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
SENIOR SUITE PROPERTIES LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 04/08/2025
SMITH FAMILY 2001 TRUSTOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 04/08/2025
NEWTON, ELIZABETHIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 06/01/2024
SENIOR SUITE CARE & REHAB LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2024
MAY, AMANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2024
SELVAGGI, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2024
SMITH, BRADLEYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2024

CMS files one row per role, so the 12 rows in the source record cover these 7 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.

3 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.

$2.5M
Net patient revenuemost recent cost report
-14.4%
Operating marginrevenue minus expenses
$317K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 63%Medicare 14%Other / private 23%

This home reported $317K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

$248per resident / day
operating cost
$7,528per month
≈ monthly operating cost
$216per day
avg. revenue, all payers

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

What families pay in TX

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676142. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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