Legend Oaks Healthcare and Rehabilitation Garland
2625 Belt Line Road, Garland, TX 75044 · For profit - Corporation · 132 certified beds · (972) 543-7700 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605) — 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 (29) — 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 (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 1 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.6% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.2% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.6% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.7% | 2.4% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 5.1% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 29.1% | 14.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.0% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.7% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.9% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 19.5% | 13.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.8% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.5% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 55.4% | 88.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 20.7% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 18.0% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.22 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.09 | 2.06 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
37.8% 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 51 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.7% 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 30 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 0.95 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 37.8%CMS range 24.8–51.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 6.8–16.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 56.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 60.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 36.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 89.3% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.1%CMS range 3.2–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.04 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 132 beds and averages 101.0 residents a day — about 77% occupied, or roughly 31 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.546 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 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 2.91 hrs/resident/day on weekends vs 3.54 on weekdays — 18% thinner on weekends. RN hours go from 0.64 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.
- Potential for harm · Ecited before2026-04-30 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed, in accordance with State and Federal laws, to ensure medications and biologicals were stored in a safe and secure manner and were not accessible to residents #17 & #21. 1. The facility failed to ensure Resident #17 did not have access to an open tube of Clear Moisture Barrier Ointment observed on the bedside table in plain view on 4/28/26. 2. The facility failed to ensure Resident #21 did not have access to an unopened packet of Essentials Prevent Ointment observed on the bedside table in plain view on 4/28/26. These failures could place residents at risk for accidental misuse or ingestion of topical medications. Findings include: 1. Record review of Resident #17's admission record dated 4/28/26 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included other cirrhosis of liver (chronic liver damage that may impair healing), thrombocytopenia (low platelet count that may increase risk for bruising and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-30 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two of twenty residents (Resident #93 and Resident #95) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #93 and Resident #95's rooms were in a position that was accessible to the residents on 04/28/2026.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Resident #93Record review of Resident #93's Face Sheet, dated 04/29/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason) and anxiety (intense or excessive fear or worry).Record review of Resident #93's Quarterly MDS Assessment (assessment used to determine…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of three residents (Residents #17) reviewed for quality of care.The facility failed to ensure that Resident #17's open wounds to her left and right buttocks were covered with dressings on 04/28/2026. This failure could place the residents with open wounds at risk for infection.Findings included: Record review of Resident #17's Face Sheet, dated 04/29/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with irritant contact dermatitis due to fecal, urinary or dual incontinence (unable to control).Record review of Resident #17's Comprehensive MDS Assessment, dated 04/02/2026, reflected that the resident was cognitively intact with a BIMS score…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the resident's environment remained free of hazards as was possible for one of six residents (Resident #24) reviewed for accident hazards. The facility failed to ensure Resident #24 had physician orders for a scoop mattress to ensure it was not a hazard for the resident. This failure could prevent the residents from having an environment that was free from accidents, and potential injury. Findings included:Record review of Resident #24's Face Sheet, dated 04/29/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #24 had a diagnosis of reduced mobility.Record review of Resident #24's Initial MDS Assessment, dated 03/19/26, reflected the resident had a BIMS score of 5 (severe cognitive impairment). The MDS assessment reflected the resident had an active diagnosis of reduced mobility.During an observation on 04/14/26 at 11:35 a.m., revealed Resident #24 was lying in bed on a scoop mattress (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-30 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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 provide appropriate treatment and services to prevent complications of enteral feeding for one of three residents (Resident #29) reviewed for feeding tube management.The facility failed to ensure LVN D flushed Resident #29's g-tube before and after medication administration as ordered on 04/29/2026.This failure could place residents with g-tubes at risk for clogging.Findings included:Record review of Resident #29's Face Sheet, dated 04/29/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing) and gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support).Record review of Resident #29's Comprehensive MDS Assessment, dated 04/17/2026, reflected the resident had a memory problem. The Comprehensive MDS Assessment indicated the resident had a feeding tube (a way of providing nutrition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of twelve residents (Resident #73, and Resident ##81) reviewed for infection control.1. The facility failed to ensure LVN D placed a cap on Resident #73's IV port after disconnecting the resident's IV on 04/28/2026.2. The facility failed to ensure on 04/28/2026 CNA E wore a gown while performing Resident #81's incontinent care, who had a permacath and was undergoing dialysis, and was on enhanced barrier precautions. Findings included:1. Record review of Resident #73's Face Sheet, dated 04/29/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with overactive bladder (a bladder control problem which leads to a sudden urge to urinate). Record review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-06 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of seven residents (Resident #1, Resident #2) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was free from abuse by Resident #2, who threw an empty plastic bowl at Resident #1. This failure could place residents at risk for abuse or neglect that could lead to serious harm. Findings included: Record review of Resident #1's face sheet, dated 03/06/26, reflected an 85- year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnosis which included: dementia (decline in memory), osteoarthritis (cartilage breakdown causing bones to rub together), type 2 diabetes mellitus (high blood sugar), hypertension (force of blood pushing against artery walls), hypothyroidism (thyroid gland does not make enough thyroid (regulates metabolism) hormones), gastro-esophageal reflux…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 interview and record review the facility failed to provide care and services, based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for one of seven residents (Resident # 3) reviewed for activities of daily living. The facility failed to ensure Resident #3 was provided with incontinent care in a timely manner. This failure could place residents at risk for poor self-esteem, infection, and diminished quality of life.Findings included: Record review of Resident #3's face sheet, dated 03/06/26, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE]. Resident #3 had diagnoses that included: chronic obstructive pulmonary disease (inflammatory lung disease), dementia with mood disturbance (emotional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-30 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one (Residents #1) of ten residents and for one (Crash Cart) of three carts reviewed for medication storage. The facility failed to ensure the crash cart (cart stocked with medical equipment, supplies, and medications used during medical emergencies) was locked on 12/30/2025. The facility failed to ensure a tube of pain relieving topical (application of medication through the skin) analgesic (painkiller) cream was not inside Resident #1's room on 12/30/2025. These failures could place the residents at risk of accessing/opening the cart, accidental overdose, adverse reactions, misuse of medications.Findings included: 1. An observation on 12/30/2025 at 8:22 AM revealed a crash cart was parked outside the nurse's station unlocked. The cart and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's sleep apnea mask was properly stored in a bag when not in use on 09/30/25. The facility failed to ensure Resident #1's nebulizer mask was properly stored in a bag when not in use on 09/30/25. The facility failed to ensure Resident #1's nasal canula attached to the oxygen tank on his wheelchair was properly stored in a bag when not in use on 09/30/25. These failures could place the resident at risk for respiratory infection and not having his respiratory needs met.Findings include: Record review of Resident #1's Face Sheet, dated 09/30/25, reflected she was a [AGE] year-old male admitted to the facility on [DATE].…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · E2025-02-20 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 13.33% based on four errors out of 30 opportunities, which involved three (Resident #28, Resident #74, and Resident #89) of six residents reviewed for medication errors. 1. The facility failed to ensure Resident #28's Glipizide (lowered blood sugar) and Benzonatate (treats cough) was administered as ordered during the scheduled timeframe of 7:00 a.m. to 10:00 a.m. 2. The facility failed to ensure Resident #74's Carvedilol (treats high blood pressure) was administered as ordered during the scheduled timeframe of 7:00 a.m. to 10:00a.m. 3. The facility failed to ensure Resident #89's Metformin (lowers blood sugar) was administered as ordered during the scheduled timeframe of 7:00 a.m. to 10:00a.m. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or not receiving…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-20 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure that food items past there expiration date were discarded. This failure could place residents at risk of exposure to food borne illnesses. Findings included: In an observation and interview on 02/18/2025 at 9:41 AM two 48-ounce plastic jars of opened Spaghetti Sauce were observed on a shelf in the walk-in refrigerator in the kitchen of the facility. Both jars were found to have no dates of when they were opened or a discard date. The Dietary Manager stated all food in the walk-in refrigerator should have an open and discard date. She stated foods that are past their discard dates could become spoiled and possibly expose residents to possible food-related illness. She stated because there were no dates on the containers, she was unable to determine when they were opened or when they should be discarded. In an interview on 2/18/2025 at 10:09 AM [NAME] F revealed that it was important…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-20 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews, the facility failed to ensure that each resident had a right to personal privacy and confidentiality of his or her own personal medical records for 1 (Resident #94) of 2 residents investigated for privacy of medical records. The facility failed to ensure when Resident #93 discharged from the facility Resident #94's Personal Private Information was not handed to Resident #93's Resident's representative. This failure could place residents at risk of having medical information exposed to others and possible misuse of personal information. Findings included: Review of an attachment to the complaint intake revealed two pictures of a document that was discerned to be Resident #94's Face Sheet which contained Resident #94's name, birthdate, social security number and all diagnosis. In an interview on 02/14/2025 at 10:21 AM with the resident representative for Resident #93 the resident representative stated that she had been at the facility to assist with the discharge of Resident #93 when she was handed Resident #93's medical/personal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-19 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 11 (Resident #1, 14, 15, 23, 36, 48, 51, 52, 56, 70, and 80's) of 27 resident rooms observed for housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The facility failed to ensure that Resident #1, 14, 15, 23, 36, 48, 51, 52, 56, 70, and 80's rooms were cleaned, sanitized, and maintained. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings included: Observation of Resident #1 and #56's room on 01/17/24 at 10:55 AM revealed the air-condition unit had black dirt stains on the top of the unit and in between the vents. The filter in the unit had a thick dust built-up. The inside main door had white and brown splash stains going down the door. In an interview on 01/17/24 at 10:57…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-19 · tag F0604 — failed to not use physical restraints improperly — patternEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 and interviews, the facility failed to ensure the resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 3 of 6 (Resident #14, #49, and #63) residents reviewed for restraints. The facility failed to ensure Residents #14 and Resident #63 had physician orders or a physician assessment for a scoop mattress. The facility failed to ensure Resident #49 had physician orders or a physician assessment for a large positioning wedge to be added to her bed. These failures could unnecessarily inhibit the residents' freedom of movement or activity. Findings included: Resident #14 Record review of Resident #14's face sheet dated 01/18/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Relevant diagnosis included Quadriplegia (paralysis of lower extremities) Record review of Resident #14's Quarterly MDS assessment dated [DATE] revealed the resident had a BIM score…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-19 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 interviews, and record review the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 3 residents (Residents #1, and #36) reviewed for ADLs care provided to dependent residents. The facility failed to ensure Resident #1, and #36 received showers consistently based on records reviewed for January 2024 and December 2023. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Included: Resident #1 Record review of Resident #1's face sheet dated 01/18/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnosis included amputation below left and right knee. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed the resident had a BIM score of 14 (cognitively intact). The resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 (Resident #14, #15, #55, and #67) of 6 residents reviewed for respiratory care. The facility failed to ensure Resident #14's tubing on his Nebulizer machine was changed within the facility policy of 7 days. The Facility failed to ensure Resident #15's mask and tubing for his BiPAP machine was cleaned and sanitized. The facility failed to ensure Resident #55's nebulizer mask was properly stored and dated. The facility failed to ensure Resident #67's humidifier had water in it. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Resident #14 Record review of Resident #14's face sheet dated 01/18/24 revealed a [AGE] year-old male who was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-19 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview, and record review, the facility failed to ensure that four (Resident #3, Resident #12, Resident #56, and Resident #58) of fifteen residents were provided medications and/or biologicals and pharmaceutical services to meet their needs. The facility failed to ensure CMA B and LVN N re-ordered medications on a timely manner for Resident #3 (Clopidogrel Bisulfate 75 mg), Resident #12 (Gabapentin capsule 100 mg), Resident #56 (Oxcarbazepine 300 mg) and Resident #58 (Levothyroxine Sodium 25 mcg). This failure could place the residents at risk of not receiving medications as ordered by the physician. Findings included: Resident # 3 Review of Resident #3's Face Sheet dated 01/19/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (insufficient oxygen in the brain causing stroke) affecting left non-dominant side and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-19 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. The facility failed to ensure food in the freezer was not exposed from air-borne contaminants. The facility failed to ensure the ice machine, located in the facility's kitchen, was thoroughly cleaned. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 01/19/24 from 09:17 AM to 09:21 AM in the facility's only kitchen revealed: o The ice machine, in the facility kitchen revealed the inside door hinges having rust on and inside the hinges. o One gallon container of dill pickle relish, located in the walk-in refrigerator, was dated 9-14 and there was no visible expiration date. o One large box of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-19 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents had the right to participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 6 residents (Resident #28) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Resident #28 prior to administering Lamictal (medicine to treat seizures and bipolar disorder). This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the risk of the medications prescribed. Findings included: Record review of Resident #28's quarterly MDS assessment, dated 12/14/23, reflected the resident was an [AGE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #68 and Resident #236) of twelve residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents # 68 and #236's rooms was in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #68 Review of Resident #68's Face Sheet dated 01/18/2024 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included secondary Parkinsonism, (movement disorder that causes tremor, stiffness, or slowing of movement) and ataxic gait (unsteady and uncoordinated way of walking). Review of Resident #68's Quarterly MDS assessment dated [DATE] reflected resident was unable 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.
- Potential for harm · D2024-01-19 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 make information on how to file a grievance or complaint available to the residents, including notifying residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing for 1 of (Resident #71) of 3 residents reviewed for grievances. 1. The facility failed to ensure Resident #71 knew how to file a grievance. The facility's failure could place the residents at risk for concerns not being reported and addressed. Findings included: Review of Resident #71's MDS assessment, dated 01/05/24, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was intact. Her diagnoses included stroke and diabetes. An interview on 01/18/24 at 10:55 AM with Resident #71 revealed she said staff had called her a liar. The resident said she did not file a grievance about the issue because she did not know how. Resident #71 said she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #44) of three residents reviewed for care plans. The facility failed to ensure a fall mat was in place per the care plan for Resident #44. This failure could place residents at risk for not receiving care consistent with their care plan. Findings included: Review of Resident #44's MDS quarterly assessment dated [DATE], reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her cognitive status was severely impaired. Her diagnoses included stroke and non-Alzheimer's disease. There were no falls documented. Review of Resident #44's Care Plan dated 05/16/23, reflected the resident had falls related to poor balance, unsteady gait, and poor safety awareness.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-19 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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 residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #76) of one resident reviewed for gastrostomy tube management. The facility failed to ensure Resident #76 had an order for the enteral feeding (intake of food directly into the stomach) downtime. This failure could place residents at risk for underfeeding or overfeeding. Findings included: Review of Resident #76's Face Sheet dated 01/19/2024 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included gastrostomy (medical procedure where a tube is inserted through the abdominal wall and into the stomach) status and dysphagia (swallowing difficulties). Review of Resident #76's Quarterly MDS assessment dated [DATE] reflected resident had moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment also indicated Resident #76 had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #43 and Resident #18) of 8 residents reviewed for infection. 1. The facility failed to ensure ADON R washed or sanitized her hands before putting on the resting hand splint to Resident 43's right hand. 2. The facility failed to ensure CNA C performed hand hygiene during incontinence care for Resident #18. Findings included: 1. Review of Resident #43's Face Sheet dated 01/19/2024 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included cerebral infarction due to embolism of left middle cerebral artery and hemiplegia and hemiparesis following cerebral infarction. Review of Resident #43's Quarterly MDS assessment dated [DATE] reflected resident was cognitively intact…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 8 of 10 sharp containers reviewed for accidents and hazards. The facility failed to ensure staff changed sharps containers prior to them becoming overfilled and becoming a hazard. This failure could place residents at risk of injury or exposure to needles contaminated with unknown biological agents. Findings included: Observation on 10/14/23 from 5:30 AM to 6:00 AM of rooms on 200, 300, and 500 Halls revealed sharps containers located inside resident rooms 211, 212, 213, 305,310, 502, 506, and 507 were over filled to the point the safety lid would not operate. Interview on 10/14/23 at 6:45 AM with LVN B revealed all nursing staff were responsible for changing out sharps containers before they were overfilled. LVN B stated overfilled sharps containers posed a risk to anyone trying to introduce another sharps into the container. Interview on 10/14/23 at 8:00 AM with the DON revealed all nursing staff were responsible for monitoring sharps…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-14 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents had the right to be free from any physical or chemical restraints imposed for the purpose of disciplie or convenience for 1 (Resident #1) of four residents reviewed for chemical restraints. The facility failed to ensure LVN A did not sedate Resident #1 with a medication not prescribed for her. This failure could place the residents at risk of injury or death. Findings included: Record review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia, reduced mobility, and emphysema. Record review of Resident #1's annual MDS, dated [DATE], revealed a BIMS score of 8, which indicated she had moderate cognitive impairment. Her Functional Status indicated she required assistance with all of her ADLs. Record review of Resident #1's care plan revealed she was resistive to care, demonstrated physical behaviors of anger by hitting staff,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-14 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services which included procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 4 residents (Resident #2) reviewed for medication administration. 1. The facility failed to ensure LVN C administered Resident #2's medications as ordered. 2. The facility failed to ensure a discontinued medication, Xanax, for Resident #1 was removed from the medication cart on 05/30/23, which resulted in the resident being administered the drug without physician orders. The failures could place residents at risk of not receiving their medications as ordered and adverse drug reactions. Findings included: 1. Record review of Resident #2's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke affecting his left side, difficulty swallowing related…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-14 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for one of four residents (Resident #1) reviewed for medications. LVN A failed to ensure Resident #1 was not administered the psychotropic drug, Xanax, on 10/02/23 that had been discontinued by the physician on 05/30/23. The failure could place residents at risk of serious adverse drug reactions. Findings included: Record review of Resident #1's, undated, admission Record reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, reduced mobility, and emphysema. Record review of Resident #1's physician orders reflected, on 01/30/23, she was prescribed Xanax 1 mg/ml, 1 ml every four hours as needed for anxiety. The order was discontinued on 05/30/23. Record review of the Xanax count sheet reflected the pharmacy delivered a 30 ml bottle to the facility on [DATE]. One dose of 0.5 ml was administered on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 3 of 5 | 2.7 | +0.3 vs chain |
| Quality measures | 2 of 5 | 4.4 | -2.4 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| EASTLAND MEMORIAL HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/01/2019 |
| HARRIS, MARTIN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/02/2024 |
| TRIEU, LOC | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | — | since 02/28/2023 |
| TAYLOR, STEPHEN | Individual | CORPORATE OFFICER | — | since 07/01/2025 |
| DUCK CREEK HEALTHCARE, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2019 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | — | since 04/01/2019 |
| NATIONAL HEALTH INVESTORS, INC. | Organization | ADP OF THE SNF | — | since 04/29/2016 |
| TEXAS NHI INVESTORS, LLC | Organization | ADP OF THE SNF | — | since 04/29/2016 |
CMS files one row per role, so the 12 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 76% 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. This home reported $859K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676413. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, 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.