Ft. Worth Southwest Nursing Center
5300 Alta Mesa Blvd, Fort Worth, TX 76133 · For profit - Corporation · 198 certified beds · (817) 346-1800 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- lower-than-typical staff turnover (27% 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 abuse, neglect, or exploitation citations (F0600, F0607, F0610) — most recent Jul 2024
- inspectors cited 3 immediate-jeopardy problems — the most serious level
- 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
- the CMS record shows $23,923 in federal fines (most recent 2024-07-04)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.5% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.8% | 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 | 0.2% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 2.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.8% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.6% | 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 | 97.4% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.7% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.0% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.7% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 84.3% | 88.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 21.1% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 15.4% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.74 | 2.17 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.75 | 2.06 | 1.80 | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
46.4% 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 59 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.2% 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 23 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 0.26 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% 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 | 46.4%CMS range 31.8–62.7 | 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 | 12.0%CMS range 8.8–17.1 | 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 | 65.2% | 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 | 60.9% | 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 | 56.5% | 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 | 42.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.5% | 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 | 0.0% | 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 | 7.8%CMS range 3.4–15.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 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 198 beds and averages 143.1 residents a day — about 72% occupied, or roughly 55 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.61 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 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 3.24 hrs/resident/day on weekends vs 3.76 on weekdays — 14% thinner on weekends. RN hours go from 0.48 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 27% 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 13 most serious are shown; the remaining 10 are one tap away and print in full.
- Immediate jeopardy · J2024-07-04 · 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 observation, interview, and record review, the facility failed to ensure residnets right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one (Residnet #1) of eight residents reviewed for abuse. The facility failed to protect Resident #1, who was unable to give consent for sexual activity, from sexual abuse after Resident #2 was discovered in her bed with his pants off and buttocks exposed, laying behind her on 06/30/24. The facility failed to put interventions in place to protect Resident #1 after allegations were made that Resident #2 placed his penis in her mouth on 06/30/24. An IJ was identified on 07/03/2024. The IJ template was provided to the facility on [DATE] at 5:32 PM. While the IJ was removed on 07/04/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation 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.
- Immediate jeopardy · J2024-07-04 · 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 observation, interview, and record review, the facility failed to implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents, establish policies and procedures to investigate any such allegations for one (Resident #1) of eight residents reviewed for abuse. The facility failed to implement their abuse, neglect, and exploitation policy to ensure Resident #1 was safe from sexual abuse when Resident #2 was found in her bed on 06/30/2024. Resident #2 had not been on any supervision from the time the incident occurred through 07/03/2024. The facility failed to follow their policy and investigate the alleged or suspected sexual abuse of Resident #1 and provide notification and information to the proper authorities according to state and federal regulations. An IJ was identified on 07/03/2024. The IJ template was provided to the facility on [DATE] at 5:32 PM. While the IJ was removed on 07/04/2024, the facility remained out of compliance at a scope of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2024-07-04 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for one (Resident #1) of eight residents reviewed for abuse. The facility failed to implement their abuse, neglect, and exploitation policy and investigate an alleged or suspected sexual assault when Resident #2 was found in Resident #1's bed on 06/30/2024. The facility did not provide notification and information to the proper authorities according to state and federal regulations. An IJ was identified on 07/03/2024. The IJ template was provided to the facility on [DATE] at 5:32 PM. While the IJ was removed on 07/04/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation…
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 before2026-05-20 · 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
Based on interview, observation and record review, the facility must store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 1 facility reviewed for storage.The facility failed to secure 10- 1 oz Zinc Oxide Ointment tubes observed on three linen cart pockets and 2- 1oz Zinc Oxide Ointment in a resident open top-drawer.This failure could place residents at risk of unauthorized access to over-the-counter drug or prescription. Findings included:During an observation on 05/20/26 at 8:25 A.M., there were two 1oz tubes of Zinc Oxide ointment in a open top drawer.During an observation on 05/20/26 at 10:10 A.M., of the linen cart side pocket revealed 2-1oz tubes of Zinc Oxide ointment. During an observation on 05/20/26 at 10:15 A.M., of the linen cart side pocket revealed 3-1oz tubes of Zinc Oxide ointment.During an observation on 05/20/26 at 10:20 A.M., of the linen cart side pocket revealed 5- 1oz tubes of Zinc oxide ointment.During an interview on 05/20/26 at 10:30 A.M., CNA A stated…
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 before2026-05-20 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record revie, the facility failed to provide a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely for 1 (Resident #1) of 5 residents reviewed for resident rights. The facility failed to provide a space free of severe hoarding of various items that left a narrow walkway of approximately 1 foot wide from Resident #1 door to bed. This failure could place residents at risk of an unsafe, unclean and uncomfortable environmentFindings included:Record review of Resident #1's face sheet, dated 05/20/26, reflected a [AGE] year-old female admitted [DATE] and readmitted on [DATE], diagnoses included unsteadiness of feet (an indicate various underlying issues, often related to balance problems), generalized anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life), major depressive disorder,…
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 · E2026-05-08 · tag F0553 — failed to let residents help plan their care — patternAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents had the right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care for 3 of 6 residents (Resident #2, Resident #3, and Resident #76) reviewed for Comprehensive Care Plan.The facility failed to ensure Resident #2, Resident #3, and Resident #76 and/or the resident's representative were invited and given the opportunity to participate in the resident's care plan meeting.This failure could place residents at risk of a loss of independence, loss of opportunity to participate in planning of their care, psychosocial health, and quality of care.In a record review of Resident #2's face sheet, dated 05/08/2026, reflected 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 · E2026-05-08 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety. The facility failed to ensure the handwashing sinks #1 and #2 garbage receptacle contained only paper towels.The facility failed to ensure that stored canned goods had uncompromised seals and were free from dents.The facility failed to ensure to discard spoiled items stored in the walk-in refrigerator.These failures could place residents at risk for food-borne illness, cross contamination, and infection.During an observation of the #1 handwashing sink's garbage receptacle on 05/06/2026 at 8:56 a.m., the following was revealed: #1 and #2 handwashing sinks garbage receptacles contained items other than disposable paper towels, including used gloves and plastic wrapping.During an observation of the dry storage room on 05/06/2026 at 9:30 a.m., the following was revealed:1x cream of celery soup 50 oz. (3 lbs. 2 oz.) written date 03/26/2026, best by date…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-08 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 catheter care for 3 of 6 residents (Resident #1, Resident #14, and Resident #122) reviewed for infection control.Resident #14's catheter bag was touching his fall mat. Resident #1 and Resident #122's catheter bags hung under their wheelchairs and touched the floor in the physical therapy room. This failure could place residents at risk for infection.Findings included: Resident #14 Record review of Resident #14's face sheet revealed a [AGE] year-old male admitted with a primary diagnosis of atherosclerotic heart disease (arteries become narrow due to build of plaque, reducing blood flow to heart). Other pertinent diagnoses include congestive heart failure (heart cannot pump enough blood), cerebral infarction…
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 · D2026-05-08 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 notify the resident and/or resident's representative(s) in writing of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 2 (Resident #32 and Resident #139) of 6 residents reviewed for discharge planning. The facility failed to notify the residents or the residents' representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understand for Resident #32 and Resident #139.The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State LTC Ombudsman involving Resident #32 and Resident #139.This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. A record review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-08 · 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 residents were free of accident hazards for 1 of 6 (Resident #72) residents reviewed for accidents hazards and supervision.The facility failed to ensure Resident #72 did not obtain electronic cigarettes in her room.This failure could place residents at risk of being in an unsafe environment and at risk of accidents and injuries.Findings included:Record review of Resident #72's face sheet, dated 05/07/2026, revealed a [AGE] year-old female admitted to the facility with a primary diagnosis of idiopathic epilepsy (seizures that occur without a known cause). Other pertinent diagnoses include abnormalities of gait and mobility (abnormal walking pattern), type 2 diabetes mellitus (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), mild cognitive impairment (noticeable cognitive decline, normal with aging), dementia (brain disease that alters brain function, causing cognitive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to adhere to the federal requirements regarding residents' rights. The facility failed ensure a safe and decent living environment for two (Resident #2 and Resident #3's rooms) of five rooms reviewed for decent living environment. 1. The facility failed to ensure Resident #2's room was free of dirt, debris, and sticky floors on 10/10/25.2. The facility failed to ensure Resident #3's broken window was repaired. These failures could place residents at risk or diminished quality of life due to the lack of a well-kept environment. Findings included: Record review of Resident #2's face sheet, dated 10/10/25, reflected a [AGE] year-old male, with an admission date of 03/31/25. Resident #2 had a diagnosis of Convulsions (involuntary, uncontrollable muscle contractions), Dysarthria (difficult or unclear articulation of speech), Need for Assistance with Personal Care, Chronic Viral Hepatitis C (long term infection of the liver), and Vascular Dementia…
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 before2025-11-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of five (Resident #1 Room) resident rooms reviewed for pharmacy services. The facility failed to ensure a tube of Zinc Oxide Ointment and a bottle of Antiseptic Skin Cleanser were not left in Resident #1's room. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.Findings included:In an observation and interview on 10/10/25 at 10:11 AM, an uncapped, 1 oz tube of Zinc Oxide ointment was observed on Resident #1's nightstand, and a 4 oz bottle of Antiseptic Skin Cleanser was observed on top of Resident #1's refrigerator, which sat on top of the nightstand. Resident #1 stated staff must have left those items in his room this morning. Resident #1 stated the staff kept all of his medications.In an interview on 10/10/25 at 10:45 AM, RN A stated the aides were responsible for applying creams and ointments. She stated…
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 · D2025-11-26 · 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 the clinical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 1 (Resident #1) of 5 residents records reviewed for treatment documentation. 1. The facility failed to document timely when Resident #1 refused to leave the courtyard area of the facility until 1:00 AM on 10/08/25. This failure could affect the residents' medical record not being an accurate representation of the resident's medical condition or medical needs. Findings included: Record review of Resident #1's face sheet, dated 10/10/25, reflected a [AGE] year-old male, with an initial admission date of 06/17/25, and a readmission date of 10/02/25. Resident #1 had a diagnoses of Parkinson's Disease (progressive disorder that affects movement, balance, and coordination), Type 2 Diabetes (body does not use insulin properly or cannot produce enough insulin), Schizoaffective Disorder (disorder 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.
Show the remaining 10 citations
- Potential for harm · Dcited before2025-11-24 · 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, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 Resident (Resident #1) of 3 residents reviewed for accident hazards/devices. The facility failed to ensure CNA A and CNA B used the required assistive device (gait belt) to transfer Resident# 1 to prevent accidents. This failure could place residents at risk of avoidable falls, injuries, and reduced safety during transfers.Findings included: Record review of Resident #1's MDS Assessment, dated 08/01/25, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE]. He had a BIMS score of 09, indicating moderate cognitive impairment. His diagnoses included Anemia (A condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), hypertension (a condition where the blood pressure is lower than normal),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-25 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to assure drugs and biologicals were secured properly in 1 (400 hall medication cart) of 6 Medication carts reviewed for drug storage. The medication cart on 400 hall was unlocked and no staff in view of the cart. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. The findings included: Observation on 04/25/25 at 6:45 AM revealed the medication cart was unlocked and parked on the far end of 400 hall at the nursing station with the drawers facing the hallways towards the exit doors. Observed no staff in view of the medication cart. Observation on 04/25/25 at 6:59 AM revealed LVN-PRN came out of a residents room and opened the top drawer of the medication cart. Interview on 04/25/25 at 7:00 AM LVN -PRN stated the medication cart should be locked when you are not using it. LVN-PRN stated residents could overdose on medication or take medications that did not belong to them. Interview on 04/25/25 at 9:01 AM RN stated the medication…
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 before2025-02-05 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for three (Residents #27, #99, and #107) of five residents and all 29 residents in the 100 Hallway reviewed for safe, clean, homelike environment. 1. The facility failed to ensure the ceiling A/C vents for Resident #27, #99 and #107's rooms were clean and not dusty on 02/03/2025. These failures could affect residents that reside on the 100 Hallway and place them at risk for not having a safe and sanitary homelike environment. Findings included: 1. Record review of Resident #27's Face Sheet, dated 02/03/25, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Type 2 diabetes, schizophrenia, which is a chronic mental illness characterized by significant disruptions in thought processes, perceptions, emotions and behaviors, and oropharyngeal dysphasia, which…
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 · E2025-02-05 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 observation, interview, 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 (Resident #78) of 8 residents reviewed for pharmacy services. The facility failed to ensure Resident #78 received the correct dosage of morphine 15 mg as ordered by his physician on 11/19/2023 when the pharmacy delivered morphine ER (extended release) 15 mg tablets on 01/09/2024. The medication had been signed as administered 37 times between 1/15/25 and 2/5/25. The discrepancy had not been detected until surveyor inquiry on 02/05/2025. This failure placed the residents at risk of not receiving medications as ordered by the physician and a not receiving the intended therapeutic effect of their medications. Findings included: Record review of Resident #78's admission Record dated 2/5/25 reflected a [AGE] year-old male admitted to the facility…
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 · E2025-02-05 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 it is free of medication error rates of five percent or greater. The facility had a medication error rate of 9%, based on 3 errors out of 32 opportunities, which involved two (Resident #107 and Resident #78) of six residents reviewed for medication administration. 1. On 2/4/25 at 7:12 AM, MA F failed to administer a medication as ordered to Resident #107 by crushing Depakote DR (an anti-seizure medication) a medication that should not be crushed and attempted to administer prior to surveyor intervention. 2. On 2/4/25 at 7:40 AM, LVN C failed to administer medications as ordered to Resident #78 when he administered Morphine extended release 15 mg instead of morphine 15 mg immediate release as ordered. LVN C administered Geri-kot (generic form of Senekot-a laxative) 8.6 mg instead of the ordered dose of Senekot Plus 8.6-50 mg (Senekot plus docusate). These failures could place residents at risk for inaccurate drug 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 before2025-02-05 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, 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 two (Resident #23 and Resident #1) of five residents, three of five pill crushers, and two of two washing machines observed for infection control. 1. The facility failed to ensure CNA A changed gloves and performed hand hygiene during incontinence care for Resident #23. 2. The facility failed to ensure CNA B changed gloves and performed hand hygiene during incontinence care for Resident #1. 3. The facility failed to ensure the pill crushers used on Medication Carts 1, 2, and 3 were clean. 4. The facility failed to ensure the facility's two washing machines were clean. These failures placed residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Record review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-05 · 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 ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 2 residents (Resident #90) reviewed for PASRR Level I screenings. The facility's PASRR Level 1 Screening dated 10/25/2023 had no indicators of dementia as a primary diagnosis or evidence of mental illness, the PASRR did not correctly identify Resident #90 as having a mental illness of bipolar disorder onset date 10/25/2023 when the facility did not complete a new PASRR Level I Screening. This failure placed residents at risk of not receiving adequate services or care related to mental illnesses. Findings included: Record review of Resident #90's admission Record dated 2/5/25 reflected a [AGE] year-old male was originally admitted to the facility on [DATE]. Record review of Resident #90's Quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 00 indicating severe cognitive impairment.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-05 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of care within 48 hours of the resident's admission for one (Resident #221) of five residents reviewed for baseline care plans. The facility failed to complete Resident #227's baseline care plan within 48 hours of admission that included the minimum required healthcare information including physician orders, dietary orders, therapy services, and social services. Resident #227 was admitted to the facility on [DATE] and her baseline care plan was not completed until 02/03/25. This failure placed residents at risk of not receiving effective and person-centered care. Findings included: Review of Resident #221's Face Sheet, dated 02/05/25, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including acute on chronic diastolic…
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 · D2025-02-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of three residents (Resident #1) reviewed for incontinence care. 1. The facility failed to ensure CNA B thoroughly cleaned Resident #1 during incontinence care. This failure could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections. Findings included: 1. Record review of Resident #1's annual MDS assessment, dated 01/14/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 5 indicating his cognitive status was severely impaired. His diagnoses included heart failure, renal failure, and diabetes. The resident was dependent on staff for toileting. The resident was always incontinent of bowel and bladder. Record review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-28 · 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 observations, record review and interviews the facility failed to ensure the resident's right to receive services in the facility with reasonable accommodation of resident needs and preferences for 5 (Residents #1, #2, #3, #4, #5) of 30 residents observed for accommodation of needs. The facility failed to ensure Residents #1, #2, #3, #4, and #5 had call lights within reach. This failure could place the residents at risk of not being able to request assistance when needed. Findings included: Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old male who had been admitted to the facility on [DATE] with diagnoses that included muscle wasting, depression and anxiety. Review of Resident #1's annual MDS, dated [DATE], revealed a BIMS score of 4, indicating severe cognitive impairment. His Functional Status revealed he required limited assistance with his ADLs. Review of Resident #1's care plan, dated 08/30/23, revealed he had an ADL deficit related to impaired cognition.…
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
$23,923 in federal fines across 1 penalty.
- $23,923 — penalty dated 2024-07-04
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.
Part of a chain
This home belongs to OPCO SKILLED MANAGEMENT — 66 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 | 3 of 5 | 2.3 | +0.7 vs chain |
| Health inspection | 2 of 5 | 2.2 | -0.2 vs chain |
| Staffing | 2 of 5 | 1.7 | +0.3 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 65 homes this chain runs (chain average 2.3★, per CMS)
Showing 40 of 65; 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 | Share | Since |
|---|---|---|---|---|
| CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/01/2021 |
| BYROM, DAVID | Individual | CORPORATE OFFICER | — | since 03/01/2015 |
| SOUTHWEST NURSING & REHAB CENTER, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| GARETZ, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| GURWITZ, SOLOMON | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/02/2025 |
| KAPLAN, ESTHER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/02/2025 |
| KAPLAN, MORDECHAI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/28/2025 |
| MINDLE, ADAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/02/2025 |
| UNGER, JEFFREY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/28/2025 |
| 5300 ALTA MESA BLVD, LLC | Organization | ADP OF THE SNF | — | since 12/01/2021 |
| CONTINUUM REHAB GROUP LLC | Organization | ADP OF THE SNF | — | since 12/01/2021 |
| MAGNOLIA REALTY, LLC | Organization | ADP OF THE SNF | — | since 12/01/2021 |
| OPCO CA SKILLED MGMT INC. | Organization | ADP OF THE SNF | — | since 12/01/2021 |
| OPCO TEXAS SKILLED MGMT LLC | Organization | ADP OF THE SNF | — | since 12/01/2021 |
| BLACKWELL, KRISTI | Individual | ADP OF THE SNF | — | since 09/30/2024 |
| VILLEGAS, RACHEL | Individual | ADP OF THE SNF | — | since 03/14/2018 |
7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675817. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-08, 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 →
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