Farwell Care and Rehabilitation Center
305 Fifth St, Farwell, TX 79325 · Government - Hospital district · 75 certified beds · (806) 481-9027 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2023
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,397 in federal fines (most recent 2023-11-02)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (61%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 fell from 3 to 1 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 | 8.6% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.7% | 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 | 0.6% | 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 | 4.5% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.8% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.2% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.0% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.8% | 9.6% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.5% | 1.5% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 77.3% | 88.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 21.7% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.4% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.40 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.47 | 2.06 | 1.80 | worse |
‡ 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.
48.9% 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 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 44 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 34% 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 | 48.9%CMS range 35.5–65.2 | 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 | 11.3%CMS range 7.5–16.3 | 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 | 65.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 50.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 65.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 3.9–13.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.83 | 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 75 beds and averages 49.2 residents a day — about 66% occupied, or roughly 26 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 3.04 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 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 2.75 hrs/resident/day on weekends vs 3.15 on weekdays — 13% thinner on weekends. RN hours go from 0.32 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 61% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · J2023-11-02 · 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 interview and record review, it was determined the facility failed to immediately inform the physician and resident representative after a significant change in condition for 1 of 6 Residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's Physician and Responsible Party after Resident #1 had a fall with injuries that resulted in a brain hematoma with a midline shift in which Resident died due to fall. The facility failed to notify Resident #1's Physician and Responsible Party after Resident #1 had a fall resulting in his head hitting the floor and sustaining a laceration to the right eyebrow/cheek. This failure could place residents at risk by causing a delay in necessary medical intervention, not allowing physician and families to be aware of any changing conditions and/or death. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:20 PM. While the immediate jeopardy was removed on [DATE] at 6:00 PM, the facility remained out of compliance at a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2023-11-02 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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, observations and record reviews, the facility failed to ensure that residents are free from neglect for 1 of 6 residents (Resident #1) reviewed for neglect. The facility failed to ensure Resident #1 was assessed after a fall on [DATE] resulting in his head hitting the floor and sustaining a laceration to the right eyebrow/cheek . The facility failed to monitor the resident after the fall and after approximately 3.5 hrs. a change in condition was noted resulting in the resident being transferred to the hospital where he expired due to a brain bleed. This failure could place residents at risk of substandard or delay of care, physical harm, or death. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:20 PM. Although the IJ was removed on [DATE] at 6:00 PM the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further…
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 · D2026-05-19 · 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 that the residents' environment remained as free from accident hazards as was possible; and that each resident received adequate supervision to prevent accident hazards for one resident (Resident #1) of 5 residents observed for accident hazards. -Resident #1 had an oxygen bottle/cylinder left unsecured in his room. This failure could lead to injuries such as bruising, skin tears, fractures, and feelings of fear and isolation. Findings include: Record review of the clinical record for Resident #1 revealed an [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include Parkinson's (a disorder of the central nervous system that affects movements toinclude tremors), acute respiratory failure (occurs when the lungs cannot adequately pull oxygen into the blood or remove carbon dioxide from the body), obstructive sleep apnea (a sleep disorder that involves cessation or significant decrease in airflow in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for respiratory care. The facility failed to store Resident #1's nasal cannula properly. This failure could place resident at risk for complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.Findings include: Record review of the clinical record for Resident #1 revealed an [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include Parkinson's (a disorder of the central nervous system that affects movements toinclude tremors), acute respiratory failure (occurs when the lungs cannot adequately pull oxygen into the blood or remove carbon dioxide from the body), obstructive sleep apnea (a sleep disorder that involves cessation or significant decrease in airflow in the presence of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-22 · 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 observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, 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, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. report an allegation of abuse to the State Survey Agency within 2 hours of the allegation for 2 of 5 residents (Resident #1 and Resident #2).The facility failed to report an incident of abuse, dated 03/27/2026,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-16 · tag F0583 — failed to protect personal privacy — patternKeep 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; it was determined the facility failed to ensure each resident was provided with the right to have personal privacy during medical treatments, for 4 (Residents #1, #4, #14, and Resident #38) of 15 residents reviewed for privacy. -RN D failed to knock or announce herself upon entering Resident #4's room or provide privacy before administering medication via peg-tub.-RN D failed to knock or announce herself upon entering Resident #38's room or provide privacy before administering an injectable medication. -RN D failed to knock or announce herself upon entering Resident #14's room or provide privacy before administering an injectable medication. -RN D failed to knock or announce herself upon entering Resident #1's room or provide privacy before administering and injectable medication. -RN A and CNA F failed to knock or announce themselves upon entering Resident #38's room or provide privacy during wound care. These failures could place residents at risk of feeling…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-16 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure 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 observation, interview, and record review, the facility failed to have nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident for 1 (RN D) of 5 staff reviewed for nursing services. -RN D failed to knock or announce herself upon entering Resident #4's room or provide privacy before administering medication via g-tub.-RN D failed to check placement of g-tube for Resident #4 before administering medication via g-tube. -RN D failed to perform hand hygiene before administering medication to Resident #4 via g-tube. -RN D failed to knock or announce herself upon entering Resident #38's room or provide privacy before performing glucose check and the administration of an injectable medication. -RN D failed to perform hand hygiene or glove change before or after preparation of glucometer, glucose check, preparation of the medication, and the administration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-16 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 15 (Resident #1, #4, #14, #27, #38, and Resident #57) Residents reviewed for infection control, in that:-RN D failed to perform hand hygiene or glove change before or after preparation of glucometer, glucose check, preparation of the medication, and the administration of Insulin for Resident #1.-RN D failed to perform hand hygiene before administering medication to Resident #4 via g-tube.-RN D failed to perform hand hygiene or glove change before or after preparation of glucometer, glucose check, preparation of the medication, and the administration of Insulin for Resident #14.-MA E failed to perform hand hygiene or don gloves to administer eye drop medication to Resident #27.-RN D failed to perform hand hygiene or glove change before or after preparation of glucometer, glucose check,…
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 before2025-12-16 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 residents had the right to formulate an advance directive for 1 (Resident #1) of 15 residents reviewed for advance directives.The facility failed to ensure Resident #1's DNR was dated by the physician, thereby rendering it invalid.This failure could place residents at risk of not having their end-of-life wishes honored. Findings Included:Record review of Resident #1's admission record dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), type 2 diabetes (insufficient production of insulin, causing high blood sugar), and heart failure (heart muscle fails to pump blood as it should). Resident #1's advance directive was listed as DNR.Record review of Resident #1's quarterly MDS completed on [DATE] revealed a BIMS score of 6 which indicated severely impaired cognition.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 · D2025-12-16 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 (Resident #7) of 5 residents reviewed for unnecessary drugs.The facility failed to ensure a gradual dose reduction of Resident #7's four psychotropic medications was attempted or contraindicated from May 2024 to December 2025.This failure could lead to residents being overmedicated.Findings Included:Record review of Resident #7's admission record dated 12/16/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), schizoaffective disorder bipolar type (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), anxiety disorder (a group 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 · D2025-12-16 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition to state designated authority for level II resident review upon a significant change in status assessment for 1 (Resident #6) of 15 residents reviewed for PASRR.The facility failed to refer Resident #6 to state designated authority for a PASRR Evaluation due to his diagnosis of PTSD.This failure could place residents at risk of not receiving necessary services or of being harmed by residents who have not been screened properly for placement in a nursing home setting.Findings Included:Record review of Resident #6's admission record dated 12/14/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified psychosis not due to a substance or know physiological condition (mental health disorder characterized by a loss of touch with reality where the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-16 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 perform a preadmission screening for individuals with a mental disorder and individuals with intellectual disability for 1 (Resident #29) of 15 residents reviewed for preadmission screening.The facility failed to perform a preadmission screening for Resident #29 prior to admission on [DATE].This failure could place residents at risk of not receiving needed services.Findings Included:Record review of Resident #29's admission record dated 12/15/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement), and psychotic disorder with hallucinations due to know physiological…
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 19 citations
- Potential for harm · Dcited before2025-12-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 2 of 15 (Residents #6 and Resident #36) Residents reviewed for care plans.1. Resident #6 had a diagnosis of PTSD, and his care plan was not specific or person-centered regarding his history of trauma and his triggers.2. Resident #36 did not have TED hose care planned had an order for TED hose daily. There was no documentation in the care plan of measurable objectives, interventions, or timeframes for how staff would meet this need.These failures could affect all residents that reside in the facility by not having their needs met and putting them at risk of being inappropriately cared for and/or re-traumatized. Findings included:1. Record review of Resident #6's admission record dated 12/14/25 revealed a [AGE] year-old male…
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 · D2025-12-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 16 residents (Resident #36) reviewed for physician orders for treatments. A. The facility failed to follow physician's orders and apply TED hose as ordered for Resident # 36. (Thrombo-Embolic Deterrent hose which are medical stockings designed to prevent blood clots to the legs). The failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings included: Record review of admission record dated 12/14/25 revealed Resident #36 was an 84-y o female admitted to the facility on [DATE] with diagnoses of heart failure, heart disease, muscle weakness, dementia and chronic kidney disease. Record review of Resident #36's care plan dated 9/29/25 documents resident is sometimes…
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 · D2025-12-16 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 (Resident #6) of 15 residents reviewed for trauma-informed care.The facility did not ensure Resident #6 had a trauma screening that identified possible triggers when Resident #6 had a history of trauma. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization. Findings Included: Record review of Resident #6's admission record dated 12/14/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified psychosis not due to a substance or know physiological condition (mental health disorder characterized by a 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 · D2025-12-16 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, 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 each resident for 1 (Unidentified Resident) of 13 who was observed for medication administration. -MA C prepared medication for 3 separate unidentified residents and was carrying 3 medication cups around dining room administering medications. -Facility failed to ensure Resident #41's medication bubble pack for her Carbidopa-Levodopa 25mg-100mg's instructions for dosing matched Resident #41's current medication orders. These failures could place residents at risk for receiving medications that do not belong to them; which could result in adverse reactions to medication, deterioration in their health, exacerbation of their disease process, and/or hospitalization. Resident #41Record review of Resident #41's clinical record revealed Resident #41 was a [AGE]…
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 before2025-12-16 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for 2 (Resident #38 and Resident #41) of 15 residents, 1 (treatment cart) of 1 treatment cart reviewed for medication storage. -RN D failed to place Resident #38's Insulin back into treatment cart before going into Resident #38's room to perform a glucose test. This failure could place residents at risk of taking medications that do not belong to them or receiving the wrong dosage of medication, which could lead to adverse reactions, increased exacerbation of disease processes, and hospitalization.Findings Included:Resident #38Record review of Resident #38's clinical record revealed Resident #38 was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses including type 2…
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 · D2025-12-16 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance for 3 (pureed bread, pureed vegetables, and pureed meat) of 5 pureed food items reviewed for meal service.A. The dietary staff did not follow recipes for preparing the pureed bread for the lunch meal on 12/14/25 and 12/15/25 which altered the flavor of the bread. B. Foods from the test tray were not prepared by methods that conserve flavor. These failures could place any resident who consumes food prepared and served by dietary services at risk for dissatisfaction with the food and possible resulting nutrition deficit. Findings Included:In an observation and interview on 12/14/25 at 10:20 am, [NAME] H stated she had already pureed the foods for lunch and pointed to the steam table. She stated she had pureed the foods at 10:00 am and had used leftover sweet potatoes from the day before in the bread. She stated she always used leftover foods to puree bread. She stated she regularly used leftover cake, fruit and sweet potatoes to puree…
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 before2025-12-16 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure walk in cooler items were properly stored, labeled, and dated.2. The facility failed to ensure proper hot holding procedures were practiced. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings Included:Observation of the walk-in cooler on 12/14/25 at 10:17 am revealed 2 trays of cake pops on the top shelf of the cooler rack. One of the 2 trays was sitting directly under a pipe with a frozen water icicle hanging from the pipe. Both trays of cake pops had not been covered, labeled or dated. In an observation and interview on 12/4/25 at 10:20 am, [NAME] H stated she had already pureed the foods for lunch and pointed to the steam table. She stated she had pureed the foods at 10:00 am and had put the foods on the steam table then. She stated there were 4…
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 · D2025-12-16 · 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, in accordance with professional standards and practices, maintain medical records on each resident that are accurately documented for 3 (Resident #6, Resident #36, and Resident #41) of 15 residents reviewed for accuracy of medical records.1. The facility failed to ensure Resident #6's EHR did not contain NP progress notes for a female resident with his same last name.2. The facility failed to ensure the nurse checking boxes in Resident #36's TAR was providing the treatment being checked off.3. Facility failed to ensure Resident #41's medication bubble pack for her Carbidopa-Levodopa 25mg-100mg's instructions for dosing matched Resident #41's current medication orders.These failures could place residents at risk of not receiving necessary and accurate care/treatment due to inaccurate medical records.Findings Included:1. Record review of Resident #6's admission record dated 12/14/25 revealed a [AGE] year-old male admitted to the facility 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 · E2025-07-23 · tag F0940 — failed to train staff — patternDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles for 5 of 5 employees (the CNA, the DA, the Hskpr, the LPN and the SW) reviewed for required trainings.The facility failed to ensure Abuse, Neglect and Exploitation Training, Fall Prevention, Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures, and Dementia Training were completed for the CNA, the DA, the Hskpr, the LPN, and the SW upon hire and prior to providing care for or working with residents.This failure could cause a lack of understanding and skill needed to provide adequate care of residents with varying conditions and levels of care. Findings included:Record review of the CNA's employee file on 07/23/2025 at 2:35M reflected no evidence she had been trained in Fall Prevention, Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures or Dementia prior to or on her first…
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 before2024-09-19 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (medication cart #2 and Nurse's medication cart) of 3 medication carts reviewed for medication storage. -medication cart #2 revealed a bottle of Melatonin with an unreadable expiration date. -5 insulin medications were found in Nurse's medication cart that had a date of 08/24 written on them. -LVN E did not lock Nurse's medication cart while she went to go and get a resident for a treatment. The facility's failure placed residents receiving medication at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident. Findings included: Observation on [DATE] at 07:51 revealed medication cart #2 had a bottle of Melatonin 1mg with 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 · D2024-09-19 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #18) of 12 Residents reviewed for resident rights. The facility failed to ensure LVN C was seated while she fed Resident #18. This failure could lead to residents' dignity being adversely affected. Findings Included: Record review of Resident #18's admission record dated 09/18/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), vitamin deficiency (low levels of essential vitamins which may result in disease), and anorexia (eating disorder characterized by inordinately low body weight and fear of gaining weight). Record review of Resident #18'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.
- Potential for harm · D2024-09-19 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on Record Review and Interview the facility failed to have a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 (September 2, 2024) day of 90 days reviewed for RN coverage. The facility failed to have a registered nurse for at least 8 consecutive hours a day on September 2, 2024. This failure could place residents at risk of not receiving the care and services needed to maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of the facility RN coverage census for the 90-day period from 07/01/2024 through 09/17/2024 revealed on 09/02/2024, only 6-hours of RN coverage was provided to the residents. In an interview with the DON on 09/17/2024 at 2:50PM revealed on 09/02/2024 RN E was scheduled to work from 8AM-5PM. RN E had given her resignation. This day was to be her last day of scheduled employment. RN E had expressed to the DON she was unhappy and did not want to be at work, in the facility, that day. The DON expressed her desire for RN E to finish her shift. RN E clocked out from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-19 · 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
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 communicable diseases and infections for 1 of 12 (Resident #8) Residents reviewed for infection control, in that: -CNA B failed to use proper hand hygiene and glove change during incontinent care of Resident #8. These failures had the potential to affect residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: Observation on 09/18/24 at 01:19 PM of incontinent care performed by CNA B and CNA A for Resident #8. CNA B and CNA A started incontinent care for resident. Both CNA's performed hand hygiene (HH) and put on gowns and gloves secondary to Resident #8 having a foley catheter in place. CNA B removed the residents brief and performed incontinent care with foley catheter care. Perineal care was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-16 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 follow policies to implement advance directives and State laws regarding advance directives for 5 of 5 residents (Residents #13, #17, #37, #39, #48) whose advance directives were reviewed. The facility failed to obtain a complete and accurate Do Not Resuscitate advance directive for Residents #13, #17, #37, #39, and #48. This failure could place residents at risk of receiving care by the facility that is against their wishes. Findings include: Resident #13 Record review of Resident #13 face sheet, not dated, revealed an [AGE] year-old female admitted to the facility 06/29/2017. Diagnoses include but are not limited to unspecified dementia, paroxysmal arial fibrillation (irregular heartbeat), and major depressive disorder. Resident #13's face sheet indicated resident is a DNR. Record review of Resident #13 Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) of 07 indicating severe cognitive impairment. 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 · Ecited before2023-08-16 · 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 interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 5 of 5 residents (Residents #13, #17, #37, #39, #48) whose care plans were reviewed. The facility failed to develop a comprehensive person-centered care plan honoring Residents #13, #17, #37, #39, and #48 advance directives. This failure could place all residents at risk of receiving care by the facility that is against resident's wishes and not creating objectives to meet resident's medical needs. Findings included: Resident #13 Record review of Resident #13's face sheet, no date, revealed an [AGE] year-old female admitted to the facility 06/29/2017. Diagnoses include but are not limited to unspecified dementia, paroxysmal arial fibrillation (irregular heartbeat), and major depressive disorder. Resident #13's face sheet indicated resident is a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-16 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to properly store, label, and date food in accordance with professional standards for food service safety. The facility failed to: 1. Store food that was not properly sealed. 2. Properly label items for proper identification. 3. Properly date items of received, opened, or use by date. This failure has the potential to affect all residents by causing food-born illnesses, weight loss, and a diminished meal experience. Findings included: On 8/14/23 at 9:39 AM, and observation of the following were found: 1. (2) 1 gallon Block and [NAME] Dill Pickle Relish with no received date. 2. (2) 20 oz yellow mustard plastic bottle with no received date. 3. (1) 20 oz Smuckers Caramel Sunday syrup with no received date. 4. (42) 2 ½ ounces Grandmas Chocolate Brownie Cookies with no received date. 5. (17) 1.5 bags Cheez-its with no received date. 6. (7) bags…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-16 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
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 2 of 2 residents (Resident #12 and Resident #14) reviewed for infection control. The facility failed to ensure that facility staff perform hand hygiene appropriately during medication preparation, medication administration and incontinent care. This failure could place the residents at an increased risk for potentially exposing them to viral infections, secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor hygiene. Findings include: Observation on 08/15/23 8:42 AM of LVN D while she was preparing medications for a g-tube medication administration. LVN D did not perform hand hygiene before preparing medications. LVN D did take a capsule and touch it with her bare hands to open capsule and placed internal medication into a soufflé cup.…
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 before2023-08-16 · 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 observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, 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, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #14) of 13 residents reviewed for abuse and neglect. The facility failed to report to the ADM and State Survey Agency a bruise on Resident #14's forehead within 24 hours of discovery of the injury.…
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 before2023-08-16 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review; it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments under the proper temperature controls and permit only authorized personnel to have access. -LVN D left medication cart unattended and unlocked on 2 separate occasions while passing medications. -Refrigerator in medication room was not kept between 36-46 degrees. These failures could place residents at risk of having unauthorized access to medications and medications not being maintained at their best therapeutic level. Findings include: Observation on 08/14/23 10:16 AM of Medication room was performed with MA F, medication refrigerator log has not been within a safe temp for medications that are stored there for the past 5 days. Current temperature of fridge is 22 degrees F. Levemir and Lorazepam have been stored in this fridge at a temp of 36-46 degrees according to the packaging that the medication is stored in. This temp range is considered to be ideal storage temp for these medications. The temp log states that the temp for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$13,397 in federal fines across 1 penalty.
- $13,397 — penalty dated 2023-11-02
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FARWELL HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | 100% | since 02/01/2014 |
| KIRKLAND, JACK | Individual | CORPORATE DIRECTOR | — | since 05/01/1991 |
| 24 KARAT VENTURES | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2026 |
| JEWELL, BILLY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2026 |
| OGBURN, SHELLI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/20/2024 |
| RANKIN, RON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2014 |
CMS files one row per role, so the 10 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675098. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-16, 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.