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Knopp Healthcare And Rehab Center INC

1208 N Llano, Fredericksburg, TX 78624 · For profit - Corporation · 119 certified beds · (830) 997-3704 Medicare & Medicaid certified

Call the home — (830) 997-3704 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jan 2026Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (1/5)

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.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1305 N Milam St · (830) 997-7626 · Call to confirm hours
Pharmacy
707 N Llano St · (830) 997-8155 · Call to confirm hours
Grocery
312 E Austin St · (830) 992-3036 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 1 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 improved from 3 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased27.9%15.8%15.4%worse
Long-stay residents who lose too much weight2.6%3.0%5.4%better
Long-stay residents with a catheter left in their bladder3.0%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection4.1%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms2.4%2.4%6.5%typical for the state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.4%3.3%3.3%typical
Long-stay residents whose ability to walk worsened47.2%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication11.6%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine95.6%98.0%95.3%typical
Long-stay residents with pressure ulcers8.4%3.8%4.7%worse
Long-stay residents with worsening bladder/bowel control25.9%13.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.8%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.5%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine47.3%88.0%79.4%worse
Short-stay residents rehospitalized after admission30.5%25.7%22.6%worse
Short-stay residents with an outpatient ER visit20.6%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.192.171.67worse
Long-stay outpatient ER visits per 1,000 resident days3.642.061.80worse

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

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

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

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

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

54.9% 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 65 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.9%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
58.6%U.S. median 56.6%
Met the expected recovery
0.48U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.11hours / resident / day
Speech therapy

Met the expected recovery: 58.6% 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 58 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 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.9%CMS range 46.3–63.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.7–14.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge58.6%56.6%Oct 2024–Sep 2025CMS 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 discharge62.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge39.7%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.3%CMS range 3.7–12.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.751.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.47
RN hours/ resident / day
0.80
LPN hours/ resident / day
1.87
Aide hours/ resident / day
3.15
Total nurse hours/ resident / day
0.38
RN hoursweekends
47.8%
Total nursing turnover
0.0%
RN turnover

How full it usually is: this home is certified for 119 beds and averages 59.4 residents a day — about 50% occupied, or roughly 60 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 3.15 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.04 hrs/resident/day on weekends vs 3.19 on weekdays — 5% thinner on weekends. RN hours go from 0.51 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as 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

6
deficiencies at the latest standard inspection (2026-01-09)
6
at the previous standard inspection (2024-10-04)

Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · E2026-01-09 · tag F0801 — pattern
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 kitchen reviewed.The facility failed to employ a qualified dietician or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified nutrition professional last employed with the facility was in October 2025.The facility failed to employ a qualified dietician who designates a person to serve as a full-time director of food and nutrition services for the facility. The person designated to serve as a director of food and nutrition services was employed for less than 25 hours per week.These failures could place residents at risk of not having their nutritional…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-09 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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, interviews and record review, the facility failed to ensure 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) in accordance with State law through established procedure. In response to allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source for 1 of 2 residents (Resident #1) reviewed for reporting allegations of abuse and neglect. The facility DON failed to identify bruising to left eyebrow and right arm as an alleged violation of injury 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond 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, interviews and record review, the facility failed to have evidence all allegations of abuse, neglect, or mistreatment were thoroughly investigated and documented for 1 of 2 residents (Resident #1) reviewed for an injury of unknown origin.The facility failed to have evidence that a thorough investigation was conducted following the allegation Resident #1 had bruising to her left side of her face and right arm and origin was unknown on 12/29/2025.This deficient practice could place residents at risk for abuse and neglect by not investigating injuries of unknown origin.The findings included:Review of Resident #1's admission record dated 1/07/2026 reflected that she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior) with late onset, major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · tag F0644 — isolated
    Coordinate 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 interview and record review, the facility failed to ensure all individuals with mental health disorders were provided with accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 4 residents reviewed for PASRR. The facility failed to ensure that Resident #7 had an accurate PASRR Level 1 Screening which indicated a diagnosis of mental illness (Bipolar Disorder) and refer Resident #7 to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.The findings included: Record review of Resident #7 face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnosis which included Bipolar Disorder (serious mental illness causing extreme mood swings, from manic highs to depressive lows), Senile Degeneration of the Brain (age related cognitive decline), Seizures (temporary disruption of brain activity from…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure the residents' environment remains was free from accidents and hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents, for 1 of 8 residents (Resident #48) and 1 facility reviewed for a wander guard system (a wander management system used in healthcare facilities to prevent residents at risk of wandering, such as those with dementia, from leaving safe areas, offering them freedom while ensuring safety through wearable devices and automated alerts. The system uses radio frequency identification technology with wristbands and door sensors that trigger alarms and notifications to staff when a resident approaches an exit, often locking doors automatically.) The wander guard system for the facility had an exit door without a functioning wander guard system. The facility failed on 01-06-206 when the door that gave access through wing-4 hallway. The door gave a person access to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-09 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 facility's reviewed for safe and functioning equipment in the laundry department. The facility had 3 commercial clothes washers with one of the three inoperable. The facility had 4 commercial clothes dryers with one of the four in-operable. This failure could place residents at risk for neglect by not having laundry services. The findings included: A record review of the facility's Resident census report dated 1/6/2026 revealed a census of 56 residents. A record review of the facility's Facility Assessment dated 8/12/2025 revealed, The purpose of this assessment is to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies. Scope: this assessment addresses the following elements: the facility's Resident population, including but not limited to: the number of residents and the facility's Resident capacity.…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-16 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety. The facility failed to recognize and dispose of food which had pests, including maggots on the food items. This failure could place residents who receive food and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation by a Life Safety Code inspector on 10/16/2024 at approximately 2:30 PM revealed an opened box of vanilla pudding cups in the dry storage area of the kitchen. Upon further inspection, the box was revealed to have a foul odor and bugs flew out of the box. Observation on 10/16/2024 at 3:55 PM revealed an opened box of vanilla pudding cups with an opened pudding container inside of the box. Inside the box and on the open pudding container were maggots and what appeared to be insect eggs on and around the pudding cups. Interview and observation on 10/16/2024 at 3:58 PM, [NAME] A stated she was not the person who put away 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-16 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 effective pest control program so that the facility is free of pests for 1 of 1 facility reviewed for physical environment. The facility was observed to have numerous crickets scattered throughout the floor of the facility both alive and dead. This failure could place residents at risk for not having a home free of pests, and a comfortable environment in which to live. The findings included: Observation on 10/16/2024 at 2:30 PM, more than 10 crickets were observed down a hallway in the facility as well as in a common sitting area of the facility. All crickets were in various stages of life, including some dead and some alive crickets. Interview on 10/16/2024 at 4:45 PM, the Administrator stated she believed the contracted pest control company would be at the facility the following day. The Administrator stated they have pest control for the crickets and that they come monthly to spray for general pests to include crickets. Record review of the facility pest control record, undated, reflected that…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-04 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure 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 its medication error rates were not 5% or greater. The facility had a medication error rate of 24%, based on 6 errors out of 25 opportunities which involved 1 of 3 residents (Resident #7) reviewed for medication administration and medication errors. 1. RN B crushed pills and capsules, 3 medications; bisacodyl 5mg delayed release, duloxetine 60mg delayed release, and divalproex 125mg delayed release, which should not be crushed per professional standards, and administered the crushed medications to Resident #7. 2. RN B administered acetaminophen 650mg, whole pill, to Resident #7 who was ordered by her physician to have crushed medications due to her swallowing difficulties. 3. RN B administered medication Carvedilol 6.25mg on 10/03/2024 at 10:01 AM, 1 hour late. 4. RN B administered medication acetaminophen 650mg on 10/03/2024 at 10:01 AM, 1 hour late. These failures could place residents at risk for not having the intended…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-04 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 of the facility's laundry department reviewed for patient care equipment in safe operating condition. The facility presented 4 installed dryers of which 2 were inoperable and the facility presented with 3 washers of which 2 were inoperable. These failures could place residents at risk for harm by the facility's inability to provide clean sanitary linens. The findings included: A record review of the facility's census Resident List Report dated 10/01/2024 revealed a census of 50 residents. During an observation on 10/01/24 at 09:59 AM, the facility's laundry department revealed 3 commercial washers of which 1 of the 3 was operational. Further review revealed 4 commercial dryers of which 2 were operational. During an interview on 10/03/2024 at 10:10 AM, laundry Aide D stated she had been the laundry attendant for the past year and of the 3 washers only 1 worked and of the 4 dryers only 2 worked. Laundry Aide…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2024-10-04 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System, within 14 days, upon a resident's transfer, reentry, discharge, and death, for 1 of 8 residents (Resident #25) reviewed for transmitted MDS data to the CMS System. The facility failed to transmit a discharge MDS assessment to the CMS system for Resident #25. This failure could place residents at risk for not having their assessments transmitted timely which could cause a delay in treatment. The findings included: A record review of Resident #25's admission record dated 10/03/2024, revealed an admission date of 05/06/2024 and a discharge date of 06/18/2024 with diagnoses which included heart disease and hypertension (high blood pressure). A record review of Resident #25's medical record revealed an admission MDS assessment dated [DATE] which revealed Resident #25 was a [AGE] year-old male admitted for care and assessed with a BIMS score of 15 which indicated no…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 3 the residents (Resident # 3) reviewed for oxygen in that: The Facility failed to ensure Residents #3's, nebulizer tubing was bagged. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications. The findings were: Record review of Resident # 3's face sheet dated 10/1/24 revealed an 84-year female admitted to the facility on [DATE] with the diagnoses that included: Chronic Obstructive Pulmonary Disease [disease is characterized by breathlessness] ,Gastroesophageal reflux disease [condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach] and Major Depressive Disorder [mood disorder that causes a persistent feeling of sadness and loss of interest] . Record review of Resident # 3's Quarterly MDS…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-04 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation , interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record, and indicate the duration for the PRN order for 1 of 3 residents (Resident #150) reviewed for pharmacy services . The facility failed to ensure Resident # 150 had a stop date for PRN Lorazepam 0.5 mg (a medicine used to treat the symptoms of anxiety) This failure could affect residents who received antipsychotic/psychoactive medications and could place residents at risk of receiving unnecessary psychotropic medications. The findings included: Record review of Resident # 150's face sheet dated 10/02/24, reveled a 98- year old female admitted to the facility on [DATE] with diagnosis that included : [Anxiety] a feeling of fear, dread, and uneasiness , Type II…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-04 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 8 residents (Resident #16) reviewed for the ability to call for staff assistance. The facility failed to ensure Resident #16's call light was within reach while she was positioned in her wheelchair. This failure could place residents at risk for delay in care and services, and increased risk of falls and injuries. The findings included: A record review of Resident #16's admission record dated 10/03/2024 revealed an admission date of 12/09/2023 with diagnoses which included Parkinson's disease (a movement disorder of the nervous system that worsens over time. Parkinson's symptoms may include tremors, slowed movement, rigid muscles, and poor balance), spinal stenosis (a condition that narrows the spaces in your spine, squeezing your spinal…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-20 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, 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, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or serious bodily injury for 1 (Resident #4) of 4 residents reviewed for freedom from abuse, neglect, and exploitation. The nursing staff of the facility failed to report an allegation of resident abuse made by Resident #4, which occurred on 09/10/24, to the administrator immediately, per facility policy. This failure could place all residents at increased risk for potential neglect due to unreported allegations of neglect. The findings included: Record review of Resident #4's admission record, dated 09/20/24, reflected a [AGE] year-old male who was re-admitted on [DATE] with no relevant diagnoses. Record review of Resident #4's quarterly MDS…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-20 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to review and revise Resident Care Plans after each assessment for 2 of 4 Residents (Resident #1 and Resident #3) whose records were reviewed for care plan revision/timing, in that:. 1. Resident #1's Care Plan was not updated after her annual MDS assessment reflected she was dependent on staff for ADL care . 2. Resident #3's Care Plan was not updated after she had a significant change and required a mechanical lift for transfers. These deficient practices could affect any resident and contribute to Residents not receiving the care and services they needed. The findings were: 1. Record review of Resident #1's admission record, dated 09/18/24, reflected a [AGE] year-old female who was admitted on [DATE] with diagnoses to include Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and weakness. Record review of Resident #1's annual MDS assessment…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-08-24 · tag F0727 — failed to provide required RN coverage — widespread
    Have 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 interview and record review, the facility failed to utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week and the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 3 of the 13 months reviewed, in that: The facility did not employ a Director of Nursing and did not employ sufficient full-time registered nurses to utilize their services for at least eight consecutive hours per day, seven days per week from July 2022 to October 2022. This deficient practice could place all residents in danger of not receiving adequate care. The findings were: During an interview with the Administrator on 08/23/2023 at 3:36 p.m., the Administrator stated the DON began working in October 2022 and prior to that, the facility had not employed a Director of Nursing since before the time of the previous re-certification survey in July 2022. The Administrator further stated the facility had not employed sufficient full-time registered nurses to utilize their services for at least eight…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-08-24 · tag F0944 — widespread
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to include as part of its QAPI program, mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program, for 20 of the 25 staff members reviewed for mandatory training, in that: Twenty of the twenty-five staff members reviewed for mandatory training had not received training regarding the facility's QAPI program. This deficient practice could place residents at risk of receiving inadequate care from staff who are unfamiliar with the facility's QAPI program. The findings were: Record review of LVN E's employee file revealed LVN E was hired on 07/27/2023 and had not received training regarding the facility's QAPI program. Record review of RN H's employee file revealed RN H was hired on 08/10/2023 and had not received training regarding the facility's QAPI program. Record review of RN I's employee file revealed RN I was hired on 06/13/2023 and had not received training regarding the facility's QAPI program. Record review of LVN J's employee file revealed LVN J was hired on 05/22/2023…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-24 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the residents' right to right to a safe, clean, comfortable and homelike environment for 3 of 3 communal shower rooms (shower room A located near the small dining room, shower room B located near conference room, and shower room C on 200 Hall) reviewed, in that: Barrels containing soiled linens and barrels containing trash were stored in three communal shower rooms, and equipment in Shower Room C was in disrepair. This deficient practice could place residents who utilize communal shower rooms at risk of psychosocial harm due to feeling disrespected or uncomfortable, with decreased self-esteem and quality of life. The findings were: Observation on 08/21/2023 at 10:42 a.m. revealed barrels containing soiled linens and barrels containing trash were in communal shower room A on the resident hallway near the small dining room. During an interview with the Social Worker on 08/21/2023 at 10:48 a.m., the Social Worker confirmed barrels containing soiled linens and barrels containing trash were in the communal…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 2 halls (disused hall near therapy gym and hall near conference room), and 1 shower room (Shower Room C) reviewed for environment, in that: Hazardous materials, sharp tools, and equipment in disrepair were found in areas accessible by facility residents. This deficient practice could place all residents at risk of injury due to exposure to hazardous materials, sharp tools, and equipment in disrepair. The findings were: Observation on 8/21/2023 at 11:41 a.m., on the 200-wing shower room (Shower Room C) on the right side of the hallway from the nurses' station, the wall next to the toilet was observed to have a missing toilet paper holder exposing the drywall behind the tiled wall. Additionally, the toilet seat had multiple gouges in the finish, mostly centered around the front of the toilet seat, which exposed the rough wood like material underneath. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-24 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 3 of 8 residents (Resident #188, #28, and #33), reviewed for resident records, in that: 1. The facility failed to ensure the Advance Directive code status was updated for Resident #188's care plan; 2. The facility failed to ensure the diet order was updated for Resident #28's care plan and physician orders; and 3. The facility failed to ensure the care plan was updated for Resident #33 to include diet orders. This deficient practice could affect all residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: 1. Record review of the admission record dated 8/24/2023 revealed Resident #188 was an [AGE] year-old female admitted on [DATE]. Diagnosis information included: heart failure; hypertension; mixed hyperlipidemia [familial combined…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-24 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 8 residents (Resident #188 and #33), reviewed for comprehensive care plans in that: 1. The advance directive code status was not updated for (Resident #188's care plan; and 2. The diet order was not updated for Resident #33's care plan. These deficient practices could affect residents with comprehensive care plans and could result in missed or delayed continuity of care. The findings included: 1. Record review of the admission record dated 8/24/2023 revealed Resident #188 was an [AGE] year-old female admitted on [DATE]. Diagnosis information included: heart failure; hypertension [high blood pressure]; mixed hyperlipidemia [combined high cholesterol, triglycerides and other lipids in the blood] and history of malignant neoplasm [cancerous tumor] of the breast.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-24 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 administration of all drugs and biologicals, to meet the needs of two of 6 residents reviewed for pharmacy services (Residents #12 and #1), in that: 1. The facility failed to ensure vital signs were obtained immediately prior to the administration of medication, metoprolol [a medication for high blood pressure], for Resident #12. 2. The facility failed to ensure that liquid medications were dispensed into a graduated receptacle for accuracy of dosing for Resident #1. These deficient practices could place residents at risk of not receiving the intended therapeutic benefit of the medications, could result in a worsening or exacerbation of chronic medical conditions, hospitalization and or a diminished quality of life. The findings included: 1. Record review of the admission record dated 8/24/2023, revealed Resident #12 was a [AGE] year-old female with an original…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-24 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, and interview, the facility failed to store all drugs and biologicals in locked compartments for one of four medication carts (200-wing treatment cart) reviewed for medication storage, in that: The facility failed to ensure the 200-wing treatment cart was unlocked and unattended at the nurses' station. This deficient practice could affect residents who have medications in the medication cart and could result in lost medications, drug diversion, or harm due to accidental ingestion or misuse of unprescribed treatments. The findings included: In an observation on 8/24/2023 at 2:00 PM, the 200-wing treatment cart was observed unlocked and unattended at the nurses' station. Staff, visitors, and ambulatory residents were in the immediate vicinity. The cart included both over the counter and prescription medications along with diabetic testing supplies, specifically lancets, and glucometer control testing solutions. The cart was next to the open door of the unoccupied nurses' station. In a group interview on 8/24/2023 at 2:11 PM with the DON, LVN D and LVN E, LVN E…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-24 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to designate a member of the facility's interdisciplinary team who was responsible for working with hospice representatives to coordinate care and failed to obtain documentation and information from the hospice company for 2 of 4 residents (Resident #7 and Resident #26) who received hospice services reviewed, in that: 1. There was not a designated member of the facility's interdisciplinary team who was responsible for working with hospice representatives to coordinate care. 2. The facility did not obtain documentation and information from the hospice company for Resident #7 and Resident #26 regarding their hospice services. This deficient practice could place residents who receive hospice services at risk of not having their needs met due to lack of communication and coordination between the facility and the provider of hospice services. The findings were: 1. During an interview with the Social Worker on 08/22/2023 at 10:15 a.m. the Social Worker 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.

    Administration Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
LUCHENBACH, JAYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER29%since 01/01/2013
MONKHOUSE, MARYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR9%since 05/01/2023
PERRY, CHASEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF5%since 01/01/2013
PERRY, JANEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF33%since 01/01/2013
DIAZ, PAMELAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/03/2010
KOTHMANN, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/27/2022

CMS files one row per role, so the 17 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$4.3M
Net patient revenuemost recent cost report
+12.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 31%Medicare 10%Other / private 60%

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

$265per resident / day
operating cost
$8,051per month
≈ monthly operating cost
$302per day
avg. revenue, all payers

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

What families pay in TX

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 455278. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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