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Prairie Estates

1350 Main St, Frisco, TX 75034 · For profit - Corporation · 180 certified beds · (214) 705-9108 Medicare & Medicaid certified

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1 immediate-jeopardy citation$24,587 in federal fines1 Medicare payment denial
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $24,587 in federal fines (most recent 2025-01-16)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing 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 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 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

Urgent care / clinic
25663 Smotherman Rd Unit 204 · (469) 430-0760 · Call to confirm hours
Pharmacy
360 Stonebrook Pkwy · (214) 296-0040 · Call to confirm hours
Grocery
2525 Main St · (469) 980-7222 · Call to confirm hours
Park
8211 Twin Falls Dr · 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 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.5%15.8%15.4%better
Long-stay residents who lose too much weight1.1%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%2.4%6.5%check this — see note marked star 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 injury1.0%3.3%3.3%better
Long-stay residents whose ability to walk worsened3.1%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.3%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine92.5%98.0%95.3%typical
Long-stay residents with pressure ulcers4.7%3.8%4.7%typical
Long-stay residents with worsening bladder/bowel control14.2%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.0%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine77.5%88.0%79.4%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.

53.6% 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 162 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.6%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
59.7%U.S. median 56.6%
Met the expected recovery
0.19U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 59.7% 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 67 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 0.19 therapist hours per resident per day in 2026Q1 — more than 19% 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 SNF53.6%CMS range 45.4–61.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 8.6–14.910.7%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 discharge59.7%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 discharge64.2%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 discharge47.8%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 identified95.5%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 setting97.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.9%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 worsened1.8%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 3.8–9.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.901.02Oct 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

0.50
RN hours/ resident / day
0.96
LPN hours/ resident / day
1.92
Aide hours/ resident / day
3.38
Total nurse hours/ resident / day
0.51
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 180 beds and averages 155.7 residents a day — about 86% occupied, or roughly 24 beds typically open. It runs fairly full. 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 3.38 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.83 hrs/resident/day on weekends vs 3.61 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.50 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

5
deficiencies at the latest standard inspection (2026-03-26)
7
at the previous standard inspection (2025-01-16)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Immediate jeopardy · J2023-09-27 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 records review, the facility failed to ensure personnel provided basic life support, which included CPR, to a resident requiring such emergency care subject to the resident's advance directives for one (Resident #1) of four residents reviewed for cardiopulmonary resuscitation. On [DATE], LVN A found Resident #1 unresponsive. LVN A said she a pulse was not felt, and a heartbeat was faintly heard. LVN A did not initiate CPR to Resident #1. LVN A failed to review Resident #1's Advance Directives choice, Full Code, when she discovered Resident #1 unresponsive. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:06 PM. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice could affect all residents who requested a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-01-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 received appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #75) of four residents reviewed for indwelling urinary catheters. The facility failed to provide physician ordered catheter care to Resident #75 and failed to notify Resident #75's NP when she experience pain and discomfort from her urinary catheter. These failures led to Resident # 75 experiencing increased pain and discomfort from her catheter and placed Resident # 75 at risk for urethral tears, dislodging of the catheter, and urinary tract infections. Findings included: Review of Resident #75's quarterly MDS Resident assessment dated [DATE] revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her active diagnoses included, coronary artery disease (heart disease), hypertension (high blood pressure), neurogenic bladder(lack of bladder control due to brain, spinal cord, or…

    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 · D2026-03-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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 resident had the right to a safe, clean, comfortable and homelike environment, including but not limited to Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 5 residents (Resident #14) reviewed for environmental conditions. The facility failed to ensure Resident #14's toilet seat was in good condition and was not broken. This failure could place residents at risk for injury and a decreased quality of life.Findings included: Observation and interview on 03/24/26 at 10:58 AM with Resident #14 stated his toilet seat had been broken for about a week. Observation of Resident #14's toilet seat in his bathroom revealed it was broken and the left side was not connected to the toilet. Resident #14 said he had told the aide and nurse about it being broken and was told someone would be by to fix it, but they never did. Resident #14 said he was scared to sit on the toilet because he did not want to fall and hurt himself. Resident #14 said he had…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-26 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 31 residents (Resident #24) reviewed for care plans. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #39's colostomy (an opening in the abdominal wall that allows waste to pass into a removeable pouch). This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included:Review of Resident #24's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included paraplegia (impairment or loss of motor sensory function in the lower half 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids 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 parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 8 residents (Resident #137) reviewed for intravenous medication. The facility failed to ensure Resident #137's intravenous medication bag and tubing were labeled with the date, time, and initials.These failures could place residents at risk for medication error, delay in medication administration, infections and cross-contamination. Findings include:Findings include:Record review of Resident #137's annual MDS Assessment, dated [DATE], reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #137's diagnoses included chronic respiratory failure with hypoxia (lungs cannot adequately transfer oxygen into the blood), hyperlipidemia (high cholesterol), Non-Alzheimer's Dementia (brain…

    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 before2026-03-26 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable) to meet the needs of each resident for 2 of 5 medication carts (Halls 100 medication Aide medication cart and Hall 900 nurses' medication cart) reviewed for medication storage .1. The facility failed to ensure expired medications were removed from the Hall 100 medication aide cart and Hall 900 nurses' medication cart. This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction.Observation on 03/25/2026 at 1:19 PM, Hall 100 medication aide cart revealed one bottle of Calcium 500mg/Vitamin D 400unit (used as dietary supplement designed to support bone health and improve calcium absorption with an expiry date of December 2025.Interview on 03/25/2026…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the storage of all drugs and biologicals were in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 of 1 resident (Resident #19) reviewed for storage of medications.The facility failed to ensure Resident #19's Oxycodone-Acetaminophen tablet was not left on his over-bed table in his room by staff.This failure could affect residents by placing residents at risk of consuming unsafe medications left at bedside unattended.Findings included:Findings included:Record review of Resident #19's face-sheet revealed a [AGE] year-old male initially admitted to facility on 10/09/2023 and readmitted on [DATE]. His diagnosis included: Unspecified Dementia, Mild Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (excessive and persistent fears or worries that interfere with daily life); Chronic Ischemic Heart Disease, Unspecified (long-term…

    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 before2026-01-30 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychological needs that were identified in the comprehensive assessment for one of five residents (Resident #1) reviewed for care planning.1. The facility failed to ensure Resident #1's care plan had a person-centered approach to address her evolving medical and dietary needs.2. The facility failed develop a care plan to address a hospitalization for pneumonia and a return the facility with continued textured diet orders, aspiration precautions and additional antibiotic treatment.These failures could place residents at risk of being inconsistently monitored, possible delayed identification of swallowing difficulty, and lack of coordinated food/dietary interventions during meals.Findings included:Record review of Resident #1's Face…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #1) of five residents reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan addressed their oral care and condition including the resident's risk and/or underlying causes (to the extent possible) of the resident's dental/oral condition and the impact upon the resident's function, mood, and cognition. This failure could place residents at risk of receiving inadequate interventions not individualized to their mental health and dental health care needs.Findings included: Record review of Resident #1's annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] with a BIMS score of 13, indicating…

    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 · D2025-11-24 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care for 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, interviews, and record reviews, the facility failed to provide or obtain from an outside source, routine and 24-hour emergency dental services to meet the needs of 1 of 5 residents (Resident #1) reviewed for dental needs. The facility failed to obtain dental services for Resident #1, who had a broken tooth and oversized dentures. This failure could place the residents at risk for not having their dental needs met.Findings included: Record review of Resident #1's annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] with a BIMS score of 13, indicating the resident was cognitively intact but at risk for mild memory/recall difficulties. Diagnoses included: recurrent depressive disorder (persistent sadness, loss of interest, and low energy that affects daily life), anxiety disorder (ongoing excessive worry and nervousness that interferes with daily life), diabetes (a condition where the body can't properly use sugar for energy, leading 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 · Fcited before2025-01-16 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, 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 kitchens reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's kitchen. These failures could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 01/14/25 beginning at 9:07 AM revealed: - 1 open bin of raw chicken open and exposed to air; and - 1 open bag of ham. Observation of a prep table located in the open area of the facility's kitchen on 01/14/25 beginning at 9:18 AM revealed: -1 box of bananas dated 01/06/25 with black spots and a bug; and - 1 box of bananas dated 01/08/25 with fuzzy white spots. An interview with the Dietary Supervisor on 01/16/25 at 4:47 PM revealed she completed walk throughs of the kitchen daily and before she left. She stated she checked produce in between food truck delivery days (Tuesdays and Thursdays). She stated she was responsible for ensuring…

    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 · D2025-01-16 · tag F0645 — isolated
    PASARR 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 interviews and record review the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) level 1 residents with mental illness were provided with a PASRR level 2 evaluation for 1 of 4 residents (Resident #91), reviewed for resident assessment. Resident #91's PASRR level 1 screening form did not reflect mental illness and the resident did not have a PASRR level II evaluation when Resident #91 had a diagnosis of schizophrenia. This could place residents at risk of not receiving necessary specialized services to meet their individual needs. Findings included: Record review of Resident #91's Quarterly MDS dated [DATE] revealed she was a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included unspecified schizophrenia (a condition where a patient's symptoms do not meet the full diagnostic criteria for schizophrenia or another more specific psychotic disorder), major depressive disorder (a mental health condition that involves persistent feelings of sadness,…

    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
Show the remaining 11 citations
  • Potential for harm · D2025-01-16 · tag F0655 — isolated
    Create 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 for the resident that met professional standards of care within 48 hours of the resident's admission for two (Resident #118 and Resident #141) of 7 residents reviewed for baseline care plans. The facility failed to complete baseline care plans for Resident #118 and Resident #141 within 48 hours of their admission. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services. Findings included: Review of Resident #118's Face Sheet, dated 01/16/25, reflected she was a [AGE] year-old female who was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with diagnoses including displaced trimalleolar fracture of the right lower leg (a break in the lower leg sections that form the ankle joint and help one move their foot 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 a resident fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings, for 1 (Resident #120) of 2 residents that were reviewed for feeding tubes. The facility failed to ensure LNV A verified G-tube (Gastrostomy tube a surgically placed tube directly into the stomach to deliver food and medicine) placement. LVN A failed to aspirate (the act of withdrawing fluid from the stomach to check G-tube placement and measure stomach content) prior to administering water flushes and medications. LVN A failed to administer G-tube water flushes by gravity (the use of gravity to move the water flushes and medications through the G-tube into the resident). This failure could place residents at risk for adverse reactions, inadequate therapy, and a decreased quality of care. Findings included: Record review of Resident #120's face sheet dated 01/16/25 reflected she was a [AGE] year-old…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0842 — failed to keep accurate, complete medical records — isolated
    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 review, the facility failed to maintain clinical records that were complete and/or accurate for one (Residents #91) of four residents reviewed for clinical records. --Resident #91 received psychotropic medications without documented diagnoses for which the medication was prescribed. These failures placed residents at risk of not having accurate clinical records completed to indicate if a medication or treatment was administered, resulting in potential medical errors and a decline in health. Findings include: Resident #91 Record review of Resident #91's Quarterly MDS dated [DATE] revealed she was a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included unspecified schizophrenia (a condition where a patient's symptoms do not meet the full diagnostic criteria for schizophrenia or another more specific psychotic disorder), major depressive disorder (a mental health condition that involves persistent feelings of sadness, hopelessness, and a 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 10 residents (Resident #75) observed for infection control. The facility failed to ensure LVN C used PPE while assessing the foley catheter on Resident #75 who was on enhanced barrier precautions. This failure could place residents at risk for cross contamination and risk of further infection. Findings included: Record review of Resident #75's admission MDS assessment dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE]. Resident#75 had a BIMS score of 15 which indicated she was cognitively intact. Diagnoses included encounter for surgical aftercare following surgery on the genitourinary system, calculus of kidney, urinary tract infection, site not specified, bladder…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-31 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #3) of five residents reviewed for resident rights. The facility failed to ensure Resident #3 provided proper consent to a facility affiliated insurance company. This failure could place residents at risk for decreased dignity. Findings included: Review of Resident #3's admission MDS assessment dated [DATE] revealed she was an [AGE] year-old female who was admitted to the facility 12/01/23. Her diagnosis included: hypertension, gastroesophageal reflux disease, urinary tract infection, non-Alzheimer's Dementia, and depression. Her BIMs score of 6 indicating she was severely cognitively impaired. She understood others and was understood by others. Review of Resident #3's Patient Choice Form dated 12/05/23 revealed the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-31 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 (Resident #1 and Resident #2) of 8 residents reviewed for environment. The facility failed to ensure the wheelchairs used by Resident #1 and Resident #2 were clean and sanitary. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: 1. An observation on 7/30/24 at 10:25 AM revealed Resident #1 was sitting in a wheelchair in the doorway to her room located on the 700 Hall. Both back wheels on her wheelchair had a thick buildup of dust and debris on all of the spoke surfaces. The metal frame of her chair along the sides and beneath her seat and surface of her brake lever were covered with a thick layer of dirt and debris. The areas surrounding the hardware on her seat were filled with a dried, thick, white substance. Resident #1 was unable to say how long her chair had looked or when it was last cleaned for her other than…

    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 before2024-01-30 · 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 acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 8 residents reviewed for pharmacy services. 1. The facility failed to administer evening medications to Resident #1 when she asked to take them at a later time. 2. The facility staff failed to document the missed medication doses or notify the physician when Resident #1's medications were not administered. These failures placed residents at risk of not receiving the therapeutic benefits of their prescribed medications. Findings included: Record review of Resident #1's Face Sheet dated 1/30/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including anemia [low blood count] in chronic kidney disease, atherosclerotic heart disease, Type 2 diabetes, chronic kidney disease stage 3,…

    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 before2023-12-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure the ice machine was maintained in a clean and sanitary manner free of white crust and scale. 2. The facility failed to ensure food items and clean dishes were kept away from soiled surfaces and airborne contaminants. 3. The facility failed to ensure Styrofoam containers were stored away from the kitchen cleaning products and equipment. 4. The facility failed to ensure the microwave was maintained in a clean and sanitary manner free of dust and sticky residue. These failures could place residents, who received food from the kitchen, at risk for food contamination and food-borne illness. Findings included: An observation and interview with the Nutrition Supervisor, on 12/12/2023 at 8:45 AM, revealed the ice machine in the food tray assembly area of the kitchen to have white crust/scale around the lid, front, and sides. She said it was cleaned weekly…

    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 · E2023-12-14 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    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 dispose of garbage and refuse properly. The facility failed to ensure the trash in the dumpster corral was contained and maintained in a sanitary condition. The failure had the potential to attract rodents and create an unsafe, unsanitary exterior. Findings included: An observation and interview with the Nutrition Supervisor and Corporate Trainer on 12/12/2023 at 9:10 AM revealed, the dumpster corral door to be open. Both dumpsters were closed but one had a clear bag of trash containing adult diapers hanging over the top of the bin. The ground in the dumpster corral was littered with trash. The Nutrition Supervisor named the trash as follows: clothes, plastic straws, rubber gloves, paper and paper products, cups, lotion bottles, and drink bottles. She said the Dietary department shared the dumpsters with nursing. She said it was dietary's responsibility to ensure the bins and the corral area was maintained in a sanitary way. She said trash should not be half in the bins and no trash should be left on 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 · D2023-12-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 (Resident #129) of 8 residents reviewed for personal care. The facility failed to provide personal care and skin care for Resident #129 by not grooming her hair. This failure could place residents who require staff assistance at risk of dermatitis, infections, and low self-esteem. Findings included: Record review of Resident #129's face sheet, dated 12/14/23, revealed Resident #129 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #129 had diagnoses of anxiety disorder, depression, disorder of muscle, and functional quadriplegia (complete inability to move due to severe disability). Record review of Resident #129's Quarterly MDS assessment, dated 12/14/23, revealed the resident had moderatly impaired cognition with a BIMS score of 12. Resident #129 was dependent on staff 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 before2023-09-27 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure the comprehensive care plan was developed within seven days after completion of the comprehensive assessment and reviewed and revised for one (Resident #1) of five residents reviewed for comprehensive care plans. The facility failed to develop a comprehensive person-centered care plan to address Full Code advanced directives for Resident #1. This failure may adversely affect resident care or treatment and risk not receiving the appropriate care and services to maintain their highest practicable well-being. Findings included: Record review of Resident #1's admission MDS (a standardized assessment tool that measures health status in nursing home residents) assessment, dated 04/06/23 revealed an [AGE] year-old female admitted to the facility on [DATE] with a BIMS score of 09, which suggested moderately impaired cognition (difficulty with problem-solving, remembering names and details, and may withdraw socially as new situations and places are…

    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

“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

$24,587 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $11,190 — penalty dated 2025-01-16
  • $13,397 — penalty dated 2023-09-27
  • Medicare payment denial — starting 2025-02-14 for 14 days

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 CANTEX CONTINUING CARE — 37 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 →

RatingThis homeChain avg
Overall 3 of 53.1-0.1 vs chain
Health inspection 3 of 52.9+0.1 vs chain
Staffing 1 of 51.9-0.9 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 36 homes this chain runs (chain average 3.1★, per CMS)
1 of 5The Carlyle at Stonebridge ParkSouthlake, TX 1 of 5The Colonnades at Reflection BayPearland, TX 1 of 5The CrescentSugar Land, TX 2 of 5Ashford GardensHouston, TX 2 of 5Magnolia ManorGroves, TX 2 of 5Palomino PlaceMesquite, TX 2 of 5Park Valley Inn Health CenterRound Rock, TX 2 of 5San RemoRichardson, TX 2 of 5SorrentoSan Antonio, TX 2 of 5Sundance Inn Health CenterNew Braunfels, TX 2 of 5The Villa At Mountain ViewDallas, TX 2 of 5Windemere At Westover HillsSan Antonio, TX 2 of 5Windsor GardensLancaster, TX 3 of 5Bel Air at TeravistaRound Rock, TX 3 of 5Fort Bend Healthcare CenterRosenberg, TX 3 of 5HollymeadFlower Mound, TX 3 of 5LarkspurLufkin, TX 3 of 5Mill CreekSilsbee, TX 3 of 5Renaissance Care CenterGainesville, TX 3 of 5Solera at West HoustonHouston, TX 3 of 5The Bradford At BrooksideLivingston, TX 3 of 5The Broadmoor at Creekside ParkThe Woodlands, TX 3 of 5The Harrison at HeritageFort Worth, TX 3 of 5The Manor at SeagovilleSeagoville, TX 4 of 5Beacon HillDenison, TX 4 of 5CarraraPlano, TX 4 of 5Oakwood Manor Nursing HomeVidor, TX 4 of 5The Belmont At Twin CreeksAllen, TX 4 of 5The Madison on MarshCarrollton, TX 4 of 5Woodville Health And Rehabilitation CenterWoodville, TX 5 of 5Bonne ViePort Arthur, TX 5 of 5Coronado At Stone OakSan Antonio, TX 5 of 5Crestview CourtCedar Hill, TX 5 of 5Laurel CourtAlvin, TX 5 of 5Palma RealMathis, TX 5 of 5Riverside OaksVictoria, TX

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 / managerTypeRoleShareSince
DALLAS COUNTY HOSPITAL DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/15/2015
CASTANEDA, EDMUNDOIndividualCORPORATE OFFICERsince 01/10/2022
CERISE, FREDERICKIndividualCORPORATE OFFICERsince 03/24/2014
SUTTON HEALTH CARE CENTER LTD COOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/15/2015
PINKINS, TELESIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/05/2022
COLEMAN, LAKEISHAIndividualADP OF THE SNFsince 09/05/2023

CMS files one row per role, so the 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$12.3M
Net patient revenuemost recent cost report
-9.5%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 74%Medicare 6%Other / private 20%

About 74% 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 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

$258per resident / day
operating cost
$7,830per month
≈ monthly operating cost
$235per 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 676145. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, 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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