Gulf Shores Rehabilitation and Healthcare Center
1301 S Terrell St, Falfurrias, TX 78355 · For profit - Corporation · 96 certified beds · (361) 325-3658 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- 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
- lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 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 | 25.4% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.4% | 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 | 0.7% | 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 | 4.1% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 31.1% | 14.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 22.8% | 18.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.5% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 12.8% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.8% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.3% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 93.5% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 14.1% | 25.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 3.1% | 12.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.07 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.26 | 2.06 | 1.80 | 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.
53.3% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 53.3%CMS range 37.6–69.4 | 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 7.0–16.3 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.4%CMS range 3.2–13.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 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 96 beds and averages 42.4 residents a day — about 44% occupied, or roughly 54 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 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.75 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.29 hrs/resident/day on weekends vs 3.76 on weekdays — 12% thinner on weekends. RN hours go from 0.41 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 35% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Dcited before2026-06-17 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained one each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of records. The facility failed to ensure Resident #1's MAR for June 2026 was appropriately and accurately completed to reflect Resident #1's behaviors, for which he was given PRN medication. This failure could place residents at risk for improper care. The findings included: Record review of Resident #1's face sheet, dated 06/16/2026, revealed a [AGE] year-old male with an original admission date of 05/30/2024, and a current admission date of 03/17/2026. Resident #1's pertinent diagnoses included Panic Disorder (an anxiety disorder characterized by frequent and unexpected panic attacks, which were sudden waves of intense fear or discomfort) and Major Depressive Disorder (a persistent feeling of sadness and loss 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 · Ecited before2026-04-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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
Based on observation and interview the facility must ensure that the resident environment remains as free of accident hazards as is possible 1.The facility failed to ensure the shower door in the 500 hall was closed shut and locked after use. 2.The facility failed to ensure the chemical storage closet in the 400 hall was closed shut was locked after use. 3.The facility failed to ensure the supply closet door in the 200 hall was locked which contained an unlocked electrical fuse box. These failures have the potential to result in serious injury. The findings included: In the initial facility observation on 04/27/26 at 9:53 AM the chemical room door of the 400 wing was left wide open containing cleaning agents for the kitchen and cleaning supplies with no staff in the hallway to monitor. In observation of the 500 wing the shower room was left unlocked after use which contained cleaning agents for hair and body the a resident with mental cognitive issues could ingest and result in harm. In observation of the 200 wing the supply closet door was left unlocked and it contained 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 · D2026-04-27 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to allow the resident's representative the right to exercise the resident's rights to the extent those rights are delegated to the representative for 1 resident (Resident #1) of six residents reviewed for resident rights. The facility failed to ensure that decisions made by the resident's representative were recognized and carried out as the resident's decisions, consistent with the authority established by court order or resident delegation, in accordance with applicable law. This failure could place residents at risk of their rights being violated.Findings included:Record Review of Resident#1's Face Sheet04/27/26 revealed he was 97 years-old, and was admitted to the facility on [DATE] with diagnoses of Dementia (A End stage renal disease (permanent, stage 5 chronic kidney failure where kidneys function at less than 15% of normal, requiring dialysis or a kidney transplant to sustain life)group of thinking an social symptoms that interferes with daily…
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 · D2026-02-19 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy for 1 (Resident #39) of 6 residents reviewed for privacy.The facility failed to ensure the WCN provided privacy for Resident #39 while performing her wound care. This failure could cause residents to feel uncomfortable, disrespected, and possibly a loss of dignity due to a lack of privacy. Findings included:Record review of Resident #39's face sheet dated 02/18/26 reflected a [AGE] year-old-female with an original admission date of 07/24/24. Diagnoses included Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities) and type 2 diabetes (insufficient insulin production in the body). Record review of Resident #39's physician orders dated 2/18/26 reflected: Cleanse wound with wound cleanser with 4x4 gauze, pat…
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 before2026-02-19 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure residents were free of any significant medication errors for one of ten residents (Resident #6) reviewed for medication errors. 1.a. The facility failed to ensure MA A administered Resident #6's blood pressure altering medication on 02/10/26, 02/11/26, 02/16/26, and 02/17/26 when his blood pressure was within the required parameters per the physician's order. b. The facility failed to ensure RN B administered Resident #6's blood pressure altering medication on 02/14/26 when his blood pressure was within the required parameters per the physician's order. These failures could place residents who receive blood pressure altering medications at an increased risk for complications such as decreased blood pressure, decreased pulse, exacerbation of symptoms and disease process, and potential hospitalization. Record review of Resident #6's admission record reflected a [AGE] year-old male originally admitted to the facility on [DATE] and most recently…
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 before2026-02-19 · 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, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 2 (Resident #39 and Resident #27) of 5 residents reviewed for infection control and transmission-based precautions, policies, and practices. The facility failed to ensure the WCN performed hand hygiene between glove changes after providing personal care to Resident #39. The facility failed to ensure the WCN wore EBP during Resident #39's wound care as indicated in the physician's orders The facility failed to ensure Resident #39's wound did not come in contact with a contaminated, soiled surface during wound care. The facility failed to ensure the WCN performed hand hygiene for at least 20 seconds or greater after completing Resident #39's wound care. The facility failed to ensure Resident #27's urinary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-16 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent mistreatment, abuse, neglect, and exploitation of residents, and misappropriation of residents' property for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA A did not inappropriately touch and kiss Resident #1. This failure could place residents at risk for abuse and psychological harm.Findings include:Record review of Resident #1's face sheet dated 07/16/25 reflected a [AGE] year-old-male with an original admission date of 04/16/25. Resident #1 had diagnoses which included bipolardisorder (mental health condition characterized by extreme mood swings), seizures (sudden surge of electrical activity in the brain that can cause involuntary movements), blindness in right eye, and anxiety (feeling of worry, nervousness, or unease). Record review of Resident #1's quarterly MDS dated [DATE], reflected a BIMS of 15 which indicated the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-07 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that all alleged violations involving the reasonable suspicion of a crime were reported immediately to a law enforcement entity for its political subdivision, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 (Resident #1 ) of 5 residents reviewed for abuse/neglect.The facility failed to report to the local law enforcement agency within the allotted time frame of 24 hours on 01/27/2025 around 8:53 AM when LVN A observed red/yellow discoloration on Resident #1's left breast and areola.This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse.The findings included:Record review of Resident #1 face sheet dated 07/07/2025 revealed Resident #1 was a [AGE] year-old- female who was initially admitted on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one of four residents (Resident #2) reviewed for accidents and supervision.The facility failed to ensure CNA A used a gait belt to transfer Resident #2 from the wheelchair to bed on 07/06/2025.This failure could place residents at risk for falls, injuries and a decline in health.Findings include:Record review of Resident #2's face sheet, dated 07/07/2025, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 diagnoses included lack of coordination, muscle wasting and atrophy (breakdown of tissue), hemiplegia (paralysis of one side of body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, abnormalities of gait and mobility, and lack of coordination.Record review of Resident #2's Quarterly MDS, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-07 · 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 to help prevent the development and transmission of disease and infection for one (Resident #2) of five residents reviewed for infection control, in that:CNA A, on 07/06/2025, did not remove her contaminated gloves nor performed hand hygiene after touching multiple surfaces prior to initiating Resident #2's perineal care. Additionally, CNA A failed to perform hand hygiene and gloves changes while performing incontinent care.These failures could place residents at risk for contamination and infection.The findings included:Record review of Resident #2's face sheet, dated 07/07/2025, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 diagnoses included lack of coordination, muscle wasting and atrophy (breakdown of tissue), hemiplegia (paralysis of 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.
Show the remaining 13 citations
- Potential for harm · E2024-12-04 · 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 to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Resident #14, Resident #24, and Resident #37) of 8 residents reviewed for care plans. 1. The facility failed to ensure that Resident #14's care plan reflected the need for Enhanced Barrier Precautions regarding Resident #14's right chest wall dialysis catheter. 2. The facility failed to ensure that Resident #24's care plan reflected the fact that the resident frequently removed her own oxygen cannula and tubing and refused to wear it. 3. The facility failed to ensure Resident #37's care plan reflected Resident #37 had an arterial wound (painful injuries in your skin caused by poor circulation) to right heel. These failures could place…
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 · D2024-12-04 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 8 residents (Resident #8) reviewed for physician notification. The facility failed to ensure RN A notified Resident #8's provider when RN A did not administer Resident #8's Tresiba as prescribed by the physician on 8 of 9 opportunities from 11/1/24 to 11/30/24. This failure could affect residents by placing them at risk of not receiving the therapeutic effects of medications, decline in health, and death. The findings included: Record review of Resident #8's admission record reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-04 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 observation, interviews and record reviews the facility failed to ensure that the comprehensive care plan was periodically reviewed and revised by a team of qualified persons after each assessment, including both the comprehensive and quarterly review assessments for 1 (Resident #14) of 8 residents reviewed for care plan revision. The facility failed to update Resident #14 ' s care plan when he no longer had a urinary catheter. This failure could place residents at risk of not receiving the care and services necessary to meet their current needs and achieve or maintain their highest practicable level of health and well-being. The findings included: Record review of Resident #14 ' s admission record reflected a [AGE] year-old male that was admitted to the facility on [DATE] with an original admission date of 3/24/23. Resident #14 ' s diagnoses included End Stage Renal Failure (a condition in which the kidneys no longer function), dependence on renal dialysis (a treatment used to remove waste and excess…
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 · D2024-12-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY F-tag initiation Based on observations, interviews and record reviews, the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 2 residents (Resident #24) reviewed for quality of care. 1. The facility failed to ensure Resident #24's implanted medi-port was accessed and flushed appropriately per policy and physician's orders. 2. The facility failed to ensure nurses documented the access and flush of the implanted med-port appropriately and accurately. 3. The facility failed to ensure the nurses were properly trained to access and flush the implanted med-port appropriately. These failures could place residents at risk for complications such as infection, blood clot, occlusion of catheter and/or infiltration. The findings include: Record review of Resident #24's face sheet revealed a [AGE] year-old female 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 · Dcited before2024-12-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of five residents (Resident #44) reviewed for accidents and hazards. The facility failed to ensure floor mats were in place beside Resident #44's bed . This failure could place residents at risk for an injury or a major injury. The findings include: Record review of Resident #44's face sheet, dated 12/02/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #44 had a diagnosis which included cerebral infarction (a serious that occurs when brain tissue die due to lack of blood flow to brain). Record review of Resident #44's Significant Change Minimum Data Set, dated [DATE] indicated she had severe cognitive impairment with unclear speech. Record review of Resident #44's care plan dated 11/26/24 indicated: The resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-04 · 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 interviews and record reviews, the facility failed to provide resident with he appropriate competencies and skills sets to provide nursing and related services to assure residents safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 1 of 5 residents (Resident #24). The facility failed to ensure that nursing staff were educated on the steps and protocols to access and flush Resident #24's implanted medi-port. These failures could place residents at risk for complications such as infection, blood clot, occlusion of catheter and/or infiltration. The findings include: Record review of Resident #24's face sheet revealed a [AGE] year-old female with an original admission date of 4/24/24 and a current admission date of 9/17/2024. Resident #24 had diagnoses which included, but are not limited to: Epilepsy (a seizure disorder), Intermittent Explosive Disorder (impulsive anger outbursts), Generalized Anxiety (anxiousness), Heart Failure,…
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 before2024-12-04 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #8) reviewed for significant medication errors. The facility failed to ensure that RN A administered Resident #8's Tresiba Flex Touch Solution Pen Injector on 8 of 9 opportunities from 11/1/24 to 11/30/24. This failure could place residents at risk of a decline in condition or hospitalization. The findings included: Record review of Resident #8's admission record reflected a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #8 ' s diagnoses included type 2 diabetes mellitus with hyperglycemia (persistently high blood sugar), type 2 diabetes mellitus with diabetic polyneuropathy (nerve damage caused by persistently high blood sugar) and cognitive communication deficit. Record review of Resident #8's quarterly MDS dated [DATE] reflected a BIMS of 8 which indicated moderate cognitive impairment. 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 · Fcited before2023-09-14 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 establish and maintain an infection prevention program to provide a safe and sanitary environment for 1 of 1 laundry room, and 1 of 1 facility reviewed for infection control, in that: The facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella can grow and spread by not testing for Legionella and not implementing a system for doing so. The facility failed to ensure laundry was disinfected properly by failing to sort garments before washing to prevent cross-contamination These failures could place all residents of the facility at risk for airborne infection and cross-contamination. The findings included: Observation of the washing machine in the laundry on 09/14/23 at 3:15 p.m. revealed blankets, sheets, towels, and gowns in the same load. There were two manufacturer posters on the wall in the laundry directly across from the washers. 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 · E2023-09-14 · 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 ad record review the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 4 of 8 residents (Resident #20, Resident #35, Resident #59, and Resident #68) reviewed for call lights in that: The facility failed to ensure Resident # 18's call light was within reach, had a clip on it, was positioned where she could use it, and was appropriate for her needs The facility failed to ensure Resident # 28's call light was within reach, had a clip on it, and was positioned where she could use it The facility failed to ensure Resident # 40's call light was within reach, had a clip on it, and was positioned where she could use it The facility failed to ensure Resident # 43's call light was within reach, had a clip on it, and was positioned where she could use it This failure could place residents at risk of being unable to call for assistance. The findings included: Record review of Resident #18's face sheet dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to offer sufficient fluid intake to maintain sufficient hydration and health for 1 of 8 residents (Resident #18) reviewed for hydration in that: Resident #18 was in her room in her bed without access to fluids. This failure had the potential to affect all residents who depended on the facility to meet their hydration needs by causing dehydration. The findings were: Record review of Resident #18's face sheet dated 05/03/22 with a re-admission on [DATE] revealed a [AGE] year-old female with diagnoses including encephalopathy (damage or disease that affects the brain when there has been a change in the way the brain works or a change in the body that affects the brain that leads to an altered mental state, leaving one confused and not acting like they usually do), muscle wasting and weakness, lack of coordination, stroke, cognitive-communication deficit, liver disease, respiratory failure, paranoia, depression, anxiety, diabetes, myasthenia…
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 · D2023-09-14 · tag F0940 — failed to train staff — isolatedDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for individuals providing services under a contractual arrangement, consistent with their expected roles for 3 of 3 contract employees (physical therapy, occupational therapy and speech therapy working) reviewed for training. The facility failed to ensure required trainings were provided for physical therapy, occupational therapy and speech therapy working in the therapy departments at the facility under a contractual agreement for the review period of September 2022 to September 2023. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. The findings were: During a record review of personnel records provided by the HR Manager for the facility occupational therapist it was revealed restraints training was last completed on 7/18/2022. During a record review of personnel records provided by the HR Manager for the facility physical therapist it was revealed restraints training was last completed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-17 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards of practice, that were complete and accurately documented, for one resident (R#2) of seven residents whose records were reviewed, in that: The facility inaccurately documented the tube feeding amount for R#2. These failures could result in residents not being provided services as needed. The findings included: R#2's Face Sheet dated 08/17/2023 reflected an [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of: gastrostomy (creation of an artificial external opening into the stomach for nutritional support) , dysphagia (trouble swallowing), Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), hypertension (high blood pressure), dementia (loss of cognitive functioning - thinking, remembering, and reasoning), and muscle wasting. R#2's Quarterly Minimum Data Set, 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.
- No harm found · C2025-03-22 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to post the daily nurse staffing data at the beginning of each shift in a prominent place, readily accessible to residents and visitors that included the facility name; the total number of hours worked per shift by the registered nurses, the licensed vocational nurses, and the certified nurse aides directly responsible for resident care for the facility for 43 of 43 days reviewed for staffing postings. The facility did not post current daily staffing information from 02/07/25 through 03/22/25. This failure could place the residents, families, and visitors at risk of not having access to information regarding the number of staff working each day to provide care on all shifts. Findings included: Observation on 03/22/25 at 8:50 a.m., Surveyor was conducting an observation of the facility and noticed the Nurse Staffing Data on the wall across from the nurse's station. The date on the Nurse Staffing Data form was 02/07/25. In an interview on 03/22/25 at 4:23 p.m., the DON said the HR person usually completed the form and posted it…
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 NEXION HEALTH — 51 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 | 2.2 | +1.8 vs chain |
| Health inspection | 4 of 5 | 2.3 | +1.7 vs chain |
| Staffing | 3 of 5 | 2.8 | +0.2 vs chain |
| Quality measures | 4 of 5 | 2.6 | +1.4 vs chain |
The other 50 homes this chain runs (chain average 2.2★, per CMS)
Showing 40 of 50; 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 |
|---|---|---|---|
| SANTANA, MARY | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2021 |
| MAK, DAVID | Individual | CORPORATE OFFICER | since 05/18/2021 |
| NEXION HEALTH AT FALFURRIAS, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2021 |
| FALLON, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2021 |
| KIRLEY, FRANCIS | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2021 |
| LEE, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2021 |
| RINER, MEERA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2021 |
CMS files one row per role, so the 8 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.
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 81% 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675630. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-19, 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.