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Avir at Granbury

600 Reunion Ct., Granbury, TX 76048 · For profit - Limited Liability company · 90 certified beds · (817) 573-3773 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 2024Behavioral-health or dementia-care citation — no harm found (F0758)2 immediate-jeopardy citations$66,367 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $66,367 in federal fines (most recent 2024-05-16)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (70%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
WIC0.4 mi
1250 Weatherford Hwy · (817) 579-6760 · Call to confirm hours
Pharmacy
420 W Pearl St · (817) 573-1143 · Call to confirm hours
Grocery
602 Thorpe Springs Rd
Park
304 E Rucker St · Typically dawn to dusk
Place of worship
1107 Weatherford Hwy · (254) 522-5330

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

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
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 increased35.7%15.8%15.4%worse
Long-stay residents who lose too much weight1.3%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 infection0.6%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 injury4.5%3.3%3.3%worse
Long-stay residents whose ability to walk worsened51.5%14.0%16.1%check this — see note marked dagger below the table
Long-stay residents on antianxiety or hypnotic medication23.1%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers11.6%3.8%4.7%worse
Long-stay residents with worsening bladder/bowel control12.7%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table25.3%9.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication11.1%1.5%1.4%worse
Long-stay hospitalizations per 1,000 resident days2.692.171.67worse
Long-stay outpatient ER visits per 1,000 resident days2.592.061.80worse

* 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.

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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.

0.46U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.31hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.081.02Oct 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

0.25
RN hours/ resident / day
0.93
LPN hours/ resident / day
1.93
Aide hours/ resident / day
3.12
Total nurse hours/ resident / day
0.16
RN hoursweekends
69.6%
Total nursing turnover
80.0%
RN turnover

How full it usually is: this home is certified for 90 beds and averages 49.1 residents a day — about 55% occupied, or roughly 41 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.12 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 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 2.65 hrs/resident/day on weekends vs 3.30 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.28 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 70% is well above the national median of 45%. 1 administrator has left in the past year.

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

7
deficiencies at the latest standard inspection (2025-06-04)
9
at the previous standard inspection (2024-05-16)

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.

28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · J2024-06-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to ensure residents were free from neglect for 1 of 3 residents (Resident #1) reviewed for abuse. When Resident #1 obtained a skin tear on 05/17/24 that reopened on 05/25/24, the facility failed to obtain treatment orders and provide wound care treatment. After the wound reopened on 5/25/24, the facility did not provide wound care until 5/30/34 when a family member changed the dressing. On 06/01/24 maggots were found in the wound and dressing. The facility did not obtain treatment orders until 06/02/24. An IJ was identified on 06/07/2024. The IJ template was provided to the facility on [DATE] at 5:13 p.m. While the IJ was removed on 06/08/2024, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of pain, mental anguish, emotional distress, diminished quality…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2024-06-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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, interviews, and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 3 residents reviewed for quality of care. When Resident #1 obtained a skin tear on 05/17/24 that reopened on 05/25/24, the facility failed to obtain treatment orders and provide wound care treatment. After the wound reopened on 5/25/24, the facility did not provide wound care until 5/30/24 when a family member changed the dressing. On 06/01/24 maggots were found in the wound and dressing. The facility did not obtain treatment orders until 06/02/24. An IJ was identified on 06/07/2024. The IJ template was provided to the facility on [DATE] at 5:13 p.m. While the IJ was removed on 06/08/2024, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-23 · 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 reviews, 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 that were identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) residents reviewed for comprehensive person-centered care plans. For Resident #1, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with measurable objectives in the focus areas of decreased functional abilities r/t impaired cognition and impaired mobility, resistive to care at times r/t new to nursing facility and adjustment to nursing facility, impaired daily decisions…

    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 · D2026-04-23 · 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 observation, interviews and record reviews, the facility failed to ensure Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability was performed prior to admission for 1 of 4 (Resident #3) reviewed for PASRR, in that: The facility admitted Resident #3, whose admission was a Pre-admission category and who had a suspicion of mental illness, prior to receiving the required PASRR II evaluation assessment and PASRR determination. This failure could affect all new residents admitted into the facility as a Preadmission with a mental condition at risk for inappropriate admissions and the inability to be evaluated and receive services in the most integrated setting appropriate to their needs.Findings included:Record review of Resident #3's Face Sheet, dated 04/21/2026, revealed a [AGE] year-old male, with an original admission date into the facility of 02/27/2026. Resident #3 was most recent admission date was 04/10/2026. Resident #5 had diagnoses which included…

    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 · Fcited before2025-12-05 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 1 of 1((11/01/2025,11/02/2025,11/08/2025,11/29/2025, and 11/30/2025) month reviewed for RN coverage.The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 5 of 30 days (11/01/2025,11/02/2025,11/08/2025,11/29/2025, and 11/30/2025).This failure could place residents at risk of not having decisions made, that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings include:Record review of the facility's RN nursing schedule for the month of November 2025 revealed there was no evidence of 8 hour RN coverage on 11/01/2025,11/02/2025,11/08/2025,11/29/2025, and 11/30/2025. During an interview on 12/05/2025 at 2:15 PM, the DON stated she started working as the interim DON on 9/18/2025. The DON stated she could not cover every shift with RN coverage. The DON…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-04 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 4 (Resident #32, Resident #25, Resident #21, and Resident #39) of 18 Residents reviewed for accuracy of assessments. The facility failed to ensure MDS dated [DATE] reflected the use of oxygen for Resident #32. The facility failed to ensure MDS dated [DATE] reflected hospice services for Resident #25. The facility failed to ensure MDS dated [DATE] reflected hospice services for Resident #21. The facility failed to ensure MDS dated [DATE], reflected the use of anti-anxiety medications for Resident #39. This failure could residents at risk of inaccurate assessments and not receiving appropriate care according to their status. Findings include: Resident #32 Review of Resident #32's electronic face sheet reflected a [AGE] year-old male originally admitted on [DATE] re-admitted on [DATE] with diagnoses that included: fusion of spine (surgery to fuse spine),…

    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 · Ecited before2025-06-04 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to 2 (West Hall medication cart and East Hall medication cart) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure the [NAME] Hall and East Hall medication carts, with prescription medications and biologicals, were secured while unattended. This failure could place residents at risk of harm or decline in health due to lack of potency of supplies, medications/biologicals or misappropriation of medications, or drug diversions. The findings included: During an observation on 06.02.2025 at 10:01 AM, the [NAME] Hall Medication cart had prescription heart medications (amiodarone, amlodipine, metoprolol), prescription depression medications (trazodone), prescription diuretics (metolazone), prescription antinausea (meclizine, ondansetron), prescription diabetes medications (glucagon, insulin), prescription inhalation medications (albuterol, ipratropium bromide, budesonide),…

    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 before2025-06-04 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. The facility failed to ensure that spoiled food items were disposed of properly. 2. The facility failed to ensure foods were labeled properly. 3. The facility failed to ensure that food items were disposed of properly. 4. The facility failed to ensure cans that were dented were removed from food storage. 5. The facility failed to ensure staff wore beard and hair coverings, that secured all hair. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation and interview on 06/02/2025 between 9:30 AM and 9:50 AM of the kitchen revealed Dietary Aide was wearing a hair net that failed to have all hair covered, and dietary aide was not wearing a beard covering over his beard. The Dietary Aide stated he was new…

    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 · E2025-06-04 · tag F0849 — pattern
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 3 (Resident #8, Resident #25, and Resident #40) of 18 residents reviewed for hospice services. 1. The facility failed to maintain required hospice forms and documentation, that included certificate of terminal illness to ensure that the needs of the resident were addressed and met 24 hours per day to ensure Resident #8, Resident #25, and Resident #40 received adequate end-of-life care. 2. The facility failed to have a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day and to have 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-04 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent 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 that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 2 (Resident #8 and Resident #39) of 18 residents reviewed for unnecessary medications. 1. The facility failed to ensure Resident #8's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. 2. The facility failed to ensure Resident #39's PRN Hydroxyzine (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications. Findings included: Resident #8 Review of Resident #8's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents were provided respiratory care received care consistent with professional standards of practice for 1 of 18 residents (Resident #32) and 1 of 1 oxygen storage room reviewed for oxygen administration. 1. The facility failed to post No Smoking sign in resident doorway for Resident #32 on 06/02/2025 & 06/03/2025 who used oxygen. 2. The facility failed to post No Smoking sign on doorway for room that oxygen was stored on 06/02/2025. These failures could place residents at risk of people not being notified of no smoking in oxygen storage or oxygen in use and prohibit smoking in any room, ward, or compartment where oxygen was in use or stored. Findings included: Resident #32 Record review of Resident #32's electronic face sheet dated 06/03/2025 reflected the resident was a [AGE] year-old male originally admitted on [DATE] and most recently re-admitted on [DATE] with diagnoses that included: fusion of spine (surgery to fuse…

    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 before2025-06-04 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 (Resident #5) of 110 residents tested for nutritive value, flavor, and appearance: The facility failed to provide palatable food served that was palatable and attractive to Residents #5, during lunch on 06/02/2025. Resident #5 received gravy on his hamburger patty. This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served. The findings included: Record review of Resident #5's face sheet dated 06/04/2025 revealed a [AGE] year-old male admitted on [DATE] with most recent readmission on [DATE] with the following diagnoses Heart failure, high blood pressure, renal failure and type 2 diabetes. Record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Patterns revealed Resident #5…

    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
Show the remaining 16 citations
  • Potential for harm · Ecited before2025-05-22 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meals tested for nutritive value, flavor, and appearance: The facility failed to provide palatable food served at an appetizing temperature to residents, during lunch on 05/21/2025. This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served. The findings included: During an observation on 05/21/2025 at 10:30 AM, in the dining room, the daily menu was posted and revealed: Pork Steak w/gravy, Black-Eyed Peas, Cauliflower with cheese, Roll and Banana Cake. During an interview on 05/21/2025 at 10:46 AM LVN B stated she had received complaints from residents stating that the food was cold. During an observation and interview on 05/21/2025 at 11:50 AM [NAME] A stated he had taken the temperature of food when he had taken it out of the oven. [NAME] A stated he would take the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-08 · 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 observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that were complete and accurately documented for 1 (Resident #1) of 5 residents reviewed for accuracy of medical records. The facility failed to accurately document Resident #1's had a bandaged area on his right elbow when he returned for the emergency room on [DATE] and accurately document an incident when Resident #1 had an open wound that was discovered infested with maggots. This failure could result in residents' records not accurately documenting interventions, monitoring, and inaccurate information provided to nursing staff and could lead to risk for errors in care and treatment. Findings included: Record review of Resident #1's Face Sheet, dated 06/04/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with of diagnoses Chronic (persisting) obstructive pulmonary disease (lung disease causing restricted airflow…

    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 · Ecited before2024-05-16 · 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 interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives based on assessed needs with the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #3, and Resident #10) of 18 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plan that included Resident #3's current code status. The facility failed to develop care plan that included Resident #10's conditions of probation. The facility failed to develop a care plan that included measurable approach/frequency for Resident #10's wounds on both lower legs. These failures could affect the residents by placing them at risk for not receiving care and services to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. Findings include: 1.Review of Resident #3's face sheet dated…

    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 · Ecited before2024-05-16 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 8(10/07/2023, 10/08/2023, 10/21/2023, 10/22/2023, 10/28/2023, 10/29/2023, 11/04/2023 and 11/05/2023) of 90 days reviewed for RN coverage. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 10/07/2023, 10/08/2023, 10/21/2023, 10/22/2023, 10/28/2023, 10/29/2023, 11/04/2023 and 11/05/2023. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Review of facility's Direct Care Staff Daily Report from 10/01/2023 to 12/31/2023, revealed on 10/07/2023, 10/08/2023, 10/21/2023, 10/22/2023, 10/28/2023, 10/29/2023, 11/04/2023 and 11/05/2023 there was no evidence of RN coverage. During an interview on 05/16/2024 at 3:15 PM the DON stated his expectation was to have RN…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-16 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the menu was followed for 3 of 4 (Residents #12, #36, #37) residents who received a pureed meal reviewed during one lunch meal observed. The facility failed to ensure residents receiving a pureed texture diet were provided the food according to the menu, including a roll. This failure could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance and/or weight loss. Findings included: 1. Resident #12 Record review of the resident #12's face sheet dated 05/16/2024 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: hypertension (high blood pressure) and depression. Record review of Resident #12's quarterly MDS dated [DATE] revealed: no BIMS score related to resident was rarely or never understood. Further review of the MDS Section K- Swallowing / Nutritional Status revealed Resident #12 had been on a mechanically altered diet while a resident. 2.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure foods were sealed and/or labeled properly in dry food storage and refrigerator. The facility failed to ensure that food items were discarded when it reached expiration date. The facility failed to ensure that meat was thawed properly. The facility failed to ensure food temperatures were taken properly. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation and interview on 05/13/2024 between at 09:50 a.m. to 10:15 a.m. of the kitchen revealed: Refrigerator 1. 1 plastic container of sliced cheese with lid not secured on right front corner. 2. 1 plastic container of chicken noodle soup with foil lid not covering front of container. 3. 1 individual see…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably 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 accommodate residents needs and preferences and accommodation of needs, for 2 (Resident #13, Resident #14) of 19 residents reviewed for dignity. The facility failed to ensure Resident #13 and Resident #14 call lights were within reach. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. Findings included: 1.Review of Resident #13's face sheet dated 05/16/2024 revealed a [AGE] year-old male admitted on [DATE] and most recently admitted on [DATE] with following diagnosis: Flaccid hemiplegia affecting right dominant side (inability to move muscles or muscle weakness on right side), sepsis (infection with inflammation throughout the body), aphasia (difficulty speaking), and dysphagia (difficulty swallowing). Review of Resident #13's significant change MDS dated [DATE] revealed: Resident #13 had no speech and rarely understood, sometimes understood others and BIMS not able…

    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 · D2024-05-16 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure resident right to formulate an advance directive for 2 of 5 residents (Resident #42 and #48) reviewed for advance directives. The facility failed to ensure that Resident #42 and #48's advanced directive consent, Out of Hospital Do Not Resuscitate (OOH-DNR) order, was signed by two witnesses. The facility failed to ensure that Resident #42 and #48's physician orders contained the most current code status. This failure could place residents at risk of receiving treatments that go against their personal preferences and does not allow them to make an informed decision about their care. Finding included: 1.Review of Resident #42's face sheet dated 05/16/2024 revealed a [AGE] year-old male admitted on [DATE] with the following diagnosis of unspecified psychosis not due to a substance or known physiological condition (condition were hallucinations or delusions may be present for unknown reason). Resident #42 had a code status of Do Not Resuscitate.…

    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 · D2024-05-16 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    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 a discharge summary that included a recapitulation of the resident's stay, medication reconciliation, and a discharge plan of care for 1 of 3 resident (Resident #50) reviewed for discharge summaries. The facility failed to complete a discharge summary with necessary medical information that the facility must furnish prior to discharge for Resident #50. The facility failed to complete a post-discharge plan of care with the participation of the Interdisciplinary team, the resident and with the resident's consent, and the resident's representative. This failure could place residents discharged from the facility at risk for incorrect, incomplete, or misleading information regarding discharge. Findings included: Review of Resident #50's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis that included: bacterial infection, heart failure, dementia, and kidney disease. Further 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-27 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (South Hall) of 4 medication carts reviewed for medication labeling and storage. The facility failed to ensure that all medications stored in South Hall medication cart were stored in their original container/packaging. The facility failed to ensure that all medications stored in South Hall medication cart were properly labeled. The facility failed to ensure that controlled medication in South Hall medication cart were stored under a double locking system. These failures placed all residents at risk of harm or decline in health due to lack of potency of medications/biologicals or misappropriation of medications. The findings included: During observation on 11/27/2023 at 10:15 a.m., the South Hall medication cart in the top drawer, there was one clear medication…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-27 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 food that accommodates resident's preferences for one (Resident #1) of four residents reviewed for food preferences. The facility failed to ensure Resident #1 did not receive her dislike food (peas) during the lunch meal on 11/22/2023 and failed to label her meal tickets with her likes and dislikes. This failure could affect all residents with food preferences and could result in a decrease in resident choices and weight loss from diminished interest in meals. The findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted on [DATE] with most recent return date 07/06/2023. Her diagnosis includes respiratory failure (lung disease), chronic obstructive pulmonary disease (lung disease), muscle weakness, atrial fibrillation (irregular pulse), heart failure (heart disease), and type 2 diabetes. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 08…

    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 · Ecited before2023-03-29 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 2 of 2 months. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 16 of 61 days. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Review of facility's RN nursing schedule from 05/01/2022-06/30/2022, revealed on 05/21/2022, 05/22/2022, 05/25/2022, 05/26/2022, 05/27/2022, 05/28/2022, 05/29/2022, 05/30/2022, 06/04/2022, 06/05/2022, 06/11/2022, 06/12/2022, 06/18/2022, 06/19/2022, 06/25/2022 and 06/26/2022 there was no evidence of RN coverage. During an interview on 03/29/2023 at 3:45PM the CCL stated her expectation was there should be at least 8 hours of RN coverage daily. The CCL stated not having RN coverage affects the residents by residents not…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-29 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure as needed (PRN) orders for psychotropics drugs were limited to 14-days, for six residents (Resident #4, Resident #11, Resident #14, Resident #22, Resident #28, and Resident #30) of twelve residents reviewed for unnecessary psychotropic medications. The facility had an order for the psychoactive medication alprazolam (Xanax) PRN (as needed) for Resident #4, Resident #14, Resident #22, Resident #28, and Resident #30, and an order for lorazepam (Ativan) PRN for Resident #11 for more than 14 days, without an evaluation by the physician(s) for the appropriateness of the medications. This failure could place all residents on psychoactive medications at risk for receiving unnecessary medications. The findings were: Record review of Resident #4's electronic face sheet revealed Resident #4 was an [AGE] year-old female admitted to the facility on [DATE]. The resident had a BIMS score of 9 out of 15 indicating moderate cognitive impairment. Resident #4's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-29 · 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 observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen's reviewed for food safety, in that: Items in freezer #1 were not labeled identify items and dated with opened/use by dates. Items in the large refrigerator were not labeled and dated with opened/use by dates past 7 days. These failures placed residents that eat food from the kitchen at risk for foodborne illnesses. Findings included: During an observation and interview on 03/27/2023 beginning at 10:45 AM of the 1 kitchen revealed: Large refrigerator 1 white container of green diced substance, that DM identified as diced peppers, not labeled to identify item, and dated 2/24. 1 white container of green diced substance, that DM identified as diced peppers, not labeled to identify item, and dated 2/16. Freezer #1 22 bags of what the DM identified as waffles not labeled to identify item and not dated with opened/use by dates. 1 bag of what the DM identified as carrots not labeled to identify item and not…

    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
  • No harm found · C2025-06-04 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based upon observation and interview, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors for 1 (06/02/2025) of 3 days reviewed for nursing services and postings. The facility failed to post in a prominent place the current number of licensed and unlicensed nursing staff on 06/02/2025. This failure could place residents, their families, and visitors at risk of not having access to information regarding staffing and facility census. Findings include: During an observation on 06/02/2025 at 9:53 a.m., daily nursing staffing posted across from nurses' station was dated 05/28/2025. During an observation on 06/02/2025 at 1:24 p.m., daily nursing staffing posted across from nurses' station was dated 05/28/2025. During an interview on 06/03/2025 at 9:40 a.m., the DON stated nurse staffing should be posted daily. He stated he was responsible for posting nurse staffing. He stated nurse staffing posting was not posted daily since 5/28/2025 because it slipped his mind. He stated that if any resident or visitor wanted 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-05-16 · tag F0910 — pattern
    Ensure resident rooms meet each resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and record review, the facility failed to have certified resident rooms equipped for adequate nursing care, comfort, and privacy for 14 (#45W, #45D, #46W, #46D, #47W, #47D, #48W, #48D 49W, #49D, #52W, #52D, #53W, #53D) of 104 certified beds. 1. The facility failed to ensure rooms #45 and #46 were certified for two Title 18 resident beds each and were not resident ready and could not easily be transitioned into resident ready rooms. The rooms were being used for activities, the shared wall between the two rooms had been knocked out to make one large room. 2. The facility failed to ensure rooms #47, #48 and #49 were certified for two Title 18 resident beds each and were not resident ready and could not easily be transitioned into resident ready rooms. The rooms were being used as a theater, the shared walls between the three rooms had been knocked out to make one large room. 3. The facility failed to ensure rooms #52 and #53 were certified for two Title 18 resident beds each and were not resident ready and could not easily be transitioned into resident ready…

    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

“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

$66,367 in federal fines across 1 penalty.

  • $66,367 — penalty dated 2024-05-16

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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.

$3.5M
Net patient revenuemost recent cost report
-12.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 85%Medicare 3%Other / private 12%

About 85% 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

$244per resident / day
operating cost
$7,414per month
≈ monthly operating cost
$216per 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 675084. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-04, 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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