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Crossroads Nursing & Rehabilitation

611 Rose Marie Blvd, Hearne, TX 77859 · For profit - Corporation · 80 certified beds · (979) 280-0440 Medicare & Medicaid certified

Call the home — (979) 280-0440 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 30 lower-level deficiencies on record (see below)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (1/5)

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

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

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

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
709 Barton St · (979) 279-3451 · Call to confirm hours
Pharmacy
118 W 4th St · (979) 279-2173 · Call to confirm hours
Grocery
917 W Brown St · (979) 279-2315 · Call to confirm hours
Park
Hearne Baseball Park · Typically dawn to dusk
Place of worship
509 W Brenken St · (979) 279-2326

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased11.9%15.8%15.4%better
Long-stay residents who lose too much weight2.8%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 symptoms1.9%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.1%3.3%3.3%better
Long-stay residents whose ability to walk worsened12.4%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.5%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers2.5%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control13.7%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.9%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%88.0%79.4%better
Short-stay residents rehospitalized after admission24.9%25.7%22.6%worse
Short-stay residents with an outpatient ER visit8.7%12.3%12.0%better

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.

56.8% 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 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.8%U.S. median 51.5%
Got home and stayed home
12.1%U.S. median 10.7%
Went back to hospital
58.3%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 58.3% 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 24 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 0.33 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 21% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.8%CMS range 47.5–69.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.1%CMS range 7.7–19.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge58.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge50.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge45.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 4.1–10.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.151.02Oct 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

0.35
RN hours/ resident / day
0.93
LPN hours/ resident / day
1.80
Aide hours/ resident / day
3.07
Total nurse hours/ resident / day
0.19
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 80 beds and averages 50.9 residents a day — about 64% occupied, or roughly 29 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 3.07 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 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 2.63 hrs/resident/day on weekends vs 3.26 on weekdays — 19% thinner on weekends. RN hours go from 0.41 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

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

Inspection trend

8
deficiencies at the latest standard inspection (2025-12-04)
4
at the previous standard inspection (2024-09-10)

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.

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.

30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.

  • Potential for harm · Ecited before2026-05-01 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    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, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three of seven residents (Resident # 1, Resident #2, and Resident #3) reviewed for activities.The facility failed to provide Resident #1, Resident #2 and Resident #3 in room activities three times per week, as care planned, during the months of March 2026 and April 2026.This failure could place residents at risk for boredom, depression, and a diminished quality of life. Findings included:1. Record review of Resident #1's face sheet, dated 05/01/2026, reflected a [AGE] year-old male, admitted [DATE], with a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-04 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    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, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three of five residents ( Resident # 5, Resident # 45 and Resident #46) reviewed for activities.The facility failed to provide Resident #5, Resident #45, and Resident #46 in room activities three to five times per week during the months of October 2025 and November 2025. This failure could place residents at risk for boredom, depression, and a diminished quality of life. Findings included: Resident #5Review of Resident # 5's face sheet, dated 12/03/2025, reflected a [AGE] year-old female 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-04 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 12.9% based on 4 out of 31 opportunities, which involved 1 of 4 residents (Resident #13) and 1 of 2 MAs (MA D) observed during medication administration reviewed for medication error. 1. The facility failed to ensure MA D failed to administer Resident #13's physician ordered medications acidophilus lactobacillus and artificial tears. 2. The facility failed to ensure MA D failed to administer Resident #13's B12 vitamin as ordered by the physician. 3. The facility failed to ensure MA D did not administer Resident #13 a multivitamin tablet without a physician order. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications and symptomatic changes in vital signs. Findings include:Review of Resident #13's face sheet dated 12/03/2025 reflected a [AGE] year-old female admitted to 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-04 · 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

    Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food under sanitary conditions in accordance with professional standards for food service safety for one of one kitchen.The facility failed to ensure Dietary Aide A and Dietary [NAME] B used proper hand hygiene during food preparation on 12/03/2025. This failure could place residents who ate food from the kitchen at risk for foodborne illness. Findings include: Observation on 12/03/2025 at 10:35 AM, Dietary Aide A was not wearing gloves when she opened the kitchen door leading from kitchen to the dining room. She touched the side of her pants with her ring, middle and fore finger on her right hand as she walked toward the back of the kitchen near the dishwashing room. She returned to the food prep table in front of the steam table without washing her hands. She began to pour salad dressing into small clear cups used for sauces or dressing. Dietary Aide A touched top of the plastic small cups with the salad dressing inside the cups. She continued to pour the dressing…

    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 before2025-12-04 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 1 of 5 residents reviewed for infection control practices. A) The facility failed to ensure the ADON used aseptic technique during wound care for Resident #16By not cleaning the wound care supplies prior to treatment, not setting up the clean field per facility policy, not performing hand hygiene or glove changes at all appropriate opportunities not performing hand hygiene or glove changes between wounds, and not re-cleaning the wounds after they were contaminated during the treatment. B) The facility failed to ensure MA D did not contaminate Resident #13's medication during medication pass by not performing hand hygiene during medication administration and not sanitizing the blood pressure cuff prior to using 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-04 · 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, record review, and interviews, the facility failed to provide the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 4 residents reviewed for accommodation of needs (Resident #33 and Resident #45. A) The facility failed to follow their facility policies and procedures and provide full time translation or interpretation services to Resident #33, a Spanish speaking resident. B) The facility failed to ensure Resident #45 specialty wheelchair was in safe working order so he could safely get out of bed. This failure could place residents at risk of miscommunication between the resident and staff, lead to misunderstandings about a resident's medical condition and treatment options, and improper care or inappropriate treatments or prescriptions. This failure further placed residents at risk for decreased quality of life, discomfort,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-04 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #33) of five residents reviewed for care plans, in that:1. The facility failed to complete a person-centered care plan for Resident #33's primary language as a Spanish . 2. The facility failed develop a care plan for Resident #33's refusals to take showers (refusal timeline unknown). This failure placed residents at risk of unaddressed needs, fragmented care, emotional distress (anxiety, depression), poor health outcomes, and a loss of dignity/autonomy, leading to a lower quality of care and not receiving goals and interventions for the residents' individual needs for person-centered care.Findings included: Record review of Resident #33's face sheet, dated 12/03/25, revealed a seventy-six-year-old male who was admitted to the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident #27 and Resident #39) reviewed for ADL care.The facility failed to ensure Resident #27 and Resident # 39's nails were cleaned and trimmed on 12/04/2025.This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.Findings included: Record review of Resident # 27's face sheet, dated 12/03/2025, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side ( a stroke where blood supply to part of the brain is cut off, causing brain cells to die. Paralysis (hemiplegia) or weakness (hemiparesis) affecting one side of the body in this…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-04 · 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 the storage of medications used in the facility in accordance with currently accepted professional principles for 1 of 3 medication carts reviewed. The facility failed to ensure potential contaminants, including personal items, were not on the medication carts. This failure could place residents at risk of receiving contaminated medications resulting in adverse health consequences. Findings include: Observation and interview on 12/03/2025 at 8:05 AM revealed MA D during medication preparation for Resident #13. MA D opened the bottom drawer of the medication cart to reveal a large bag. MA D removed a blood pressure cuff from the bag. MA D stated the bag was hers, and that the blood pressure cuff was her personal blood pressure cuff. In an interview on 12/03/2025 at 8:49 AM, MA D stated she did not know she could not put her bag on the medication cart, and did not know why she should not have her bag on the medication cart. In an interview on 12/04/2025 at 9:30 AM, the RNC stated staff should absolutely…

    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 · Dcited before2025-09-03 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 interview and record review, the facility failed to immediately inform the resident representative when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 of 5 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's responsible party after Resident #1 experienced an unwitnessed fall on 08/12/2025 that resulted in an abrasion. This deficient practice could place residents at risk of not having their responsible party notified of changes, resulting in a delay in medical intervention and decline in health.Findings included: Review of Resident #1's face sheet dated 09/03/2025 reflected she was admitted to the facility on [DATE] Fracture of left femur (left hip fracture) unsteadiness on feet, diabetes mellitus type II (A condition results from insufficient production of insulin, causing high blood sugar.) and osteoarthritis (happens when the protective cartilage that cushions…

    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
Show the remaining 20 citations
  • Potential for harm · Dcited before2025-09-03 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop, and implement a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Residents #1) reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan updated interventions after Resident #1 experienced multiple falls. This deficient practice placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury, a decline in physical, mental and/or psychosocial well-being.Findings include:Review of Resident #1's face sheet dated 09/03/2025 reflected she was admitted to the facility on [DATE] Fracture of left femur (left hip fracture) unsteadiness on feet, diabetes mellitus type II (A condition results from insufficient production of insulin, causing high blood sugar.) and osteoarthritis (happens when…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for falls. The facility failed to develop and implement individualized interventions for Resident #1 after the resident experienced multiple falls. This failure placed residents with falls at risk of injury, pain, bruises, fractures, dislocation of joints, and/or significant changes in condition.Findings included: Review of Resident #1's face sheet dated 09/03/2025 reflected she was admitted to the facility on [DATE] Fracture of left femur (left hip fracture) unsteadiness on feet, diabetes mellitus type II (A condition results from insufficient production of insulin, causing high blood sugar.) and osteoarthritis (happens when the protective cartilage that cushions the ends of the bones wears down over time.), left knee. Review of Resident #1's quarterly MDS dated [DATE] reflected she was assessed…

    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 before2024-11-20 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to implement a comprehensive person-centered care plan for one (1) resident (Resident #1) of six (6) residents reviewed for care plans. The facility failed to ensure Resident #1 care plan was updated and revised after behavior events on 11/2/2024 and 11/7/2024, causing Resident #1 injuries to her face on 11/7/2024. This failure placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury and a decline in physical well-being for residents. Findings included: 1. Review of Resident #1's face sheet dated 11/19/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Dementia (memory loss disorder), Diabetes Mellitus (blood sugar disorder), senile degeneration of the brain (age related brain disorder) and abnormality of gait and mobility. Review of Resident #1's admission MDS dated [DATE] reflected a BIMS of 0 suggesting severe…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-10 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for two of five (Resident #7 and Resident #47) residents reviewed for dignity. 1. The facility failed to ensure Resident #7 had a privacy cover on their urinary catheter bag. 2. The facility failed to ensure Resident #47 was served lunch at the same time as the other residents at her table for two days. These failures could affect the resident's dignity and affect their quality of life. Findings included: 1. Review of Resident #7's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] and 07/21/2024 with diagnoses of surgical amputation of left leg below knee, hypertension (elevated blood pressure), and type 2 diabetes (disease that affects how your body uses insulin and glucose). Review of Resident #7's Quarterly MDS assessment,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-10 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 immediately inform the resident's Physician when the nurse was unable to follow wound care orders for one of one Residents (Resident #49) reviewed for physician notification of changes. The facility failed to ensure RN C notified the Physician and family of her inability to follow wound care orders for Resident #49. This failure could have delayed the progress of the coccyx wound healing for Resident #49. Findings included: Record review of the undated Face Sheet for Resident #49 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of Pressure Ulcer of sacral (bony area of the spine) region, Stage 4 (open sore extending into muscles, tendons (cord like tissues that connect muscles to bones or other structures), and ligaments (short band of connective tissue which connects two bones or holds together a joint), can also expose bone). Record review of the Quarterly MDS assessment dated [DATE] for…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #49) of two residents reviewed for pressure injuries. The facility failed to ensure RN C followed Physician's orders for wound care for Resident #49. The facility failed to ensure RN C documented the wound care she provided for Resident #49 without a Physician order. These failures could have delayed the progress of the coccyx wound healing for Resident #49. Findings included: Record review of the undated Face Sheet for Resident #49 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of Pressure Ulcer of sacral (bony area of the spine) region, Stage 4 (open sore extending into muscles, tendons (cord like tissues that connect muscles to bones or other structures), and ligaments (short band of connective…

    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 before2024-09-10 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to 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 one of one Residents (Resident #49) reviewed for pressure ulcers wound care. The facility failed to ensure RN A followed standard precautions during wound care for Resident #49's Stage 4 coccyx pressure ulcer when she contaminated supplies prior to wound care and used contaminated scissors to cut foam used for wound care which she then placed into the open wound. This failure could place residents at risk for developing wound infections. Findings included: Record review of the undated Face Sheet for Resident #49 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of Pressure Ulcer of sacral (bony area of the spine) region, Stage 4 (open sore extending into muscles,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 2 (Resident #1 and Resident #2) of 4 residents reviewed for respiratory care. The facility failed to ensure that Resident #1's oxygen tubing with nasal cannula and humidifier bottle was replaced every seven (7) days. The facility failed to ensure that Resident #1's air concentrator filter was cleaned and free of dust and debris particles. The facility failed to ensure that Resident #2's Nebulizer tubing and mask, which included the nebulizing chamber (unit into which liquid medicine is converted into aerosol or mist by the pressurized air pumped through the tubing), was replaced every seven (7) days. These failures could place residents at risk for respiratory compromise and infection. Findings Included: A) Review of Resident #1's Face Sheet dated 06/20/2024 reflected a [AGE] year-old female admitted to 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 before2024-05-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (Resident #1, Resident #2, and Resident #3) of 5 residents reviewed for medication/treatment errors. The facility failed to follow physician's orders for providing wound care to Resident #1, Resident #2, and Resident #3, on a regular basis. This failure could place residents at risk of delay in wound infection and healing process. Findings Included: Record review of Resident #1's admission record dated 05/24/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Hyperlipidemia (Excess fat in blood), Hypertension, Osteomyelitis of vertebra ( infection on the vertebra), Protein-calorie malnutrition, Cerebral infarction (Stroke), Blindness right eye, Low vision left eye,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-24 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 residents' right to privacy for 1 of 1 resident (Resident #3) reviewed for privacy. The facility failed to ensure DON, RN A and CNA A provided privacy by closing the privacy curtain during wound care for Resident #3. This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life. The findings include: Record review of Resident #3's admission record dated 05/24/24 revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, but were not limited to, Psychotic Disturbance, Mood disturbance, Anxiety, Hemiplegia and Hemiparesis (weakness or paralysis on one side of the body), Alcohol Dependence, Dysphagia ( difficulty to swallow), Need for assistance with personal care, Hypertension, Cerebral infarction (Stroke), Lack of coordination and Cognitive communication deficit. Record review…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to develop and implement a comprehensive person care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one of five residents reviewed for care plans. (Resident #1). The facility failed to develop and implement a person-centered care plan for Residents #1. This deficient practice placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury and a decline in physical well-being Findings Included: Record review of Resident #1's face sheet, dated 03/12/2024, reflected a [AGE] year-old male was admitted to the facility on [DATE] with the following diagnoses which included abnormalities of gait and mobility (unable to walk in a typical way), unsteadiness on feet ( can increase your risk for falls and injury- when you are not stable when walking), difficulty with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accidents and hazards. The facility failed to ensure Resident #1's new intervention of a fall mat was placed on the right side of bed when Resident #1 was lying in bed. This failure could result in residents experiencing accidents, injuries, unrelieved pain, and diminished quality of life. Findings include: 1. Record review of Resident #1's face sheet, dated 03/12/2024, reflected a [AGE] year-old male was admitted to the facility on [DATE] with the following diagnoses which included abnormalities of gait and mobility (unable to walk in a typical way), unsteadiness on feet ( can increase your risk for falls and injury- when you are not stable when walking), difficulty with walking (loss of balance, where one faces difficulty in taking steps), unspecified dementia, unspecified severity, without…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-26 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 promote resident self-determination through support of family choice for 1 of 17 residents reviewed for resident rights. (Resident #33) The facility did not assist Resident #33 out of bed when family requested. This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life. Findings included: Record review of a face sheet dated 07/24/23 revealed Resident #33 was [AGE] years old and was admitted on [DATE] with diagnoses including stroke, high blood pressure, and lack of coordination. Record review of current physician's orders for Resident #33 indicated an open-ended order with a start date of 10/07/22 to Please have resident up in Geri chair during day as tolerated per family request. Record review of the most recent MDS dated [DATE] indicated Resident #33 was rarely to never understood and rarely to never understood others. The MDS indicated a BIMS of 00 indicating…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-26 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 3 of 20 residents reviewed for care plans. (Resident #51, Resident #28, and Resident #33) The facility failed to develop a comprehensive person-centered care plan including an active problem of bowel and bladder incontinence, oxygen usage, and risk for malnutrition for Resident #51. The facility failed to develop a comprehensive person-centered care plan including an active problem of pain, use of foley catheter, use of diuretics, use of opioid medications, and need for assistance with ADLs for Resident #28. The facility failed to develop a comprehensive person-centered care plan for Resident #33 that included a physician's order to have the resident up and in Geri chair (a chair used for those with mobility issues and can be used for bedridden residents who have difficulty sitting upright) during the day. These…

    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 · E2023-07-26 · 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 5 of 24 residents (Resident #50, Resident #21, Resident #10, Resident #29, and Resident #18). The facility failed to follow the menu. The facility failed to update residents' meal tickets to match what they were served. These failures could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life. Findings included: Record review of the facility's menu for 7/24/23 revealed the lunch meal consisted of BBQ pork on bun, chuckwagon beans, hot southwest potato salad, BBQ relish, cherry fried pie, and iced tea. Record review of the facility's menu for 7/25/23 revealed the lunch meal consisted of fried chicken with southern chicken gravy, mashed potatoes, collard greens, cornbread, margarine, strawberry shortcake, and iced tea. 1.Record review of a face sheet dated 7/25/23 revealed Resident #50 was a [AGE] year-old female, who admitted to the facility 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-26 · tag F0641 — isolated
    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 interview and record review, the facility failed to ensure an accurate MDS assessment was completed for 1 of 14 residents reviewed for MDS accuracy. (Resident #26) The facility failed to document visual impairment and anti-anxiety use on the MDS for Resident #26. These failures could place residents at risk for not receiving needed care and services. Findings included: Record review of a face sheet dated 07/24/2023 revealed Resident # 26 was a [AGE] year-old-male admitted to the facility on [DATE] with the diagnoses of Multiple sclerosis (a potentially disabling disease of the brain and spinal cord (central nervous system), legal blindness (your vision is 20/200 or less in your better eye or your field of vision is less than 20 degrees), and anxiety ( a feeling of fear, dread, and uneasiness). Record review of a quarterly MDS dated [DATE] revealed Resident #26 had a BIMS of 14 which indicated minimal cognitive impairment. The MDS revealed Resident #26 required extensive to dependent assistance with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-26 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care for 2 of 17 residents reviewed for baseline care plans. (Resident #49 and Resident #54) The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #49. The facility failed to develop a complete baseline care plan for Resident #54. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of a face sheet dated 7/25/23 revealed Resident #49 was a [AGE] year-old female, who admitted to the facility on [DATE], with the diagnoses of dementia (progressive or persistent loss of intellectual functioning; impairment of memory, thinking, and often personality changes), weakness, hypertension (high blood pressure), congestive heart failure (the heart does not pump blood as well as it should),…

    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 before2023-07-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 16 residents reviewed for ADLs (Residents #25.) The facility did not clean or trim Resident #25's fingernails. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. The findings were: Review of Resident #25's electronic face sheet dated 01/9/2022 revealed he was a [AGE] year old male admitted to the facility on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), urinary tract infection (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract), lack of coordination (Uncoordinated movement is due to a muscle control…

    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 · D2023-07-26 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing 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 ensure that 1 of 17 residents reviewed for vision services, received proper treatment and assistive devices to maintain vision abilities. (Resident #33) The facility did not address Resident #33's need for a vision exam. This failure could affect residents by causing them to have decreased vision awareness when ambulating, difficulty seeing and participating in activities, and decreased self-esteem. Findings included: Record review of a face sheet dated 07/24/23 revealed Resident #33 was [AGE] years old and was admitted on [DATE] with diagnoses including changes in retinal vascular appearance (retinal vascular conditions generally involve a blockage of blood low, leakage of fluid, or rupture of a retinal vessel in eye), left eye primary optic atrophy (damage to the optic nerve), and stroke. Record review of the most recent MDS dated [DATE] indicated Resident #33 was rarely to never understood and rarely to never understood others. The MDS indicated a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 4 residents reviewed for respiratory care. (Resident #15 and Resident #51). 1. The facility failed to ensure Resident #15's oxygen concentrator had a filter in place to change weekly per physician orders. 2. The facility failed to ensure Resident #51's nasal cannula was sanitarily stored when not in use. These failures could place residents at risk of respiratory infections. Findings included: 1. Record review of Resident #15's face sheet dated 7/24/23 revealed she was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #15 had diagnoses of dementia (progressive or persistent loss of intellectual functioning, impairment in memory, thinking, personality change caused by disease of the brain), hypertension (high blood pressure), anxiety (feeling of fear, dread, and uneasiness), and depression (persistent feeling 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CREATIVE SOLUTIONS IN HEALTHCARE — 149 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.1+0.9 vs chain
Health inspection 3 of 52.7+0.3 vs chain
Staffing 1 of 51.1-0.1 vs chain
Quality measures 5 of 53.2+1.8 vs chain
The other 148 homes this chain runs (chain average 2.1★, per CMS)
1 of 5Afton Oaks Nursing and Rehabilitation CenterHouston, TX 1 of 5Arlington Heights Health and Rehabilitation CenterFort Worth, TX 1 of 5Beltline Healthcare CenterGarland, TX 1 of 5Bluebonnet Nursing & RehabilitationKarnes City, TX 1 of 5Bluebonnet Point WellnessBullard, TX 1 of 5Brentwood Terrace Healthcare And RehabilitationParis, TX 1 of 5Buena Vida Nursing and Rehab-San AntonioSan Antonio, TX 1 of 5Cottonwood Nursing & RehabilitationDenton, TX 1 of 5Countryview Nursing & RehabilitationTerrell, TX 1 of 5Dogwood Trails ManorWoodville, TX 1 of 5Downtown Health and Rehabilitation CenterFort Worth, TX 1 of 5Estates Healthcare and Rehabilitation CenterFort Worth, TX 1 of 5Fair Park Health & Rehabilitation CenterDallas, TX 1 of 5Five Points Nursing & Rehabilitation of College StCollege Station, TX 1 of 5Five Points at Lake Highlands Nursing and RehabDallas, TX 1 of 5Five Points of PflugervillePflugerville, TX 1 of 5Franklin Heights Nursing & RehabilitationEl Paso, TX 1 of 5Gilmer Nursing & RehabilitationGilmer, TX 1 of 5Grace Pointe Wellness CenterEl Paso, TX 1 of 5Graham Oaks Care CenterGraham, TX 1 of 5Granbury Care CenterGranbury, TX 1 of 5Greenhill VillasMount Pleasant, TX 1 of 5Heritage At Longview Healthcare CenterLongview, TX 1 of 5Huebner Creek Health & Rehabilitation CenterSan Antonio, TX 1 of 5Interlochen Health and Rehabilitation CenterArlington, TX 1 of 5Kenedy Health & RehabilitationKenedy, TX 1 of 5Kennedy Health & RehabLufkin, TX 1 of 5Lake Lodge Nursing & RehabilitationLake Worth, TX 1 of 5Lampstand Nursing and RehabilitationBryan, TX 1 of 5Lancaster Nursing & RehabilitationLancaster, TX 1 of 5Marine Creek Nursing & RehabilitationFort Worth, TX 1 of 5Mesa Vista Inn Health CenterSan Antonio, TX 1 of 5Mountain View Health & RehabilitationEl Paso, TX 1 of 5Navasota Nursing & RehabilitationNavasota, TX 1 of 5Normandy Terrace Nursing & Rehabilitation CenterSan Antonio, TX 1 of 5North Pointe Nursing and RehabilitationWatauga, TX 1 of 5Park Place Care CenterGeorgetown, TX 1 of 5Parkview Manor Nursing and RehabilitationWeimar, TX 1 of 5Peach Tree PlaceWeatherford, TX 1 of 5Pebble Creek Nursing CenterEl Paso, TX

Showing 40 of 148; 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 / managerTypeRoleShareSince
FANNIN COUNTY HOSPITAL AUTHORITYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 10/01/2024
HOLT, ERINIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICERsince 10/01/2024
KEETON, WENDYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICERsince 10/01/2024
KISSLING, MONICAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICERsince 10/01/2024
MCBEAN, PATRICIAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICERsince 10/01/2024
SANDERSON, CLARKIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICERsince 10/01/2024
TROMPLER, KELLYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICERsince 10/01/2024
HUGGINS, LINDAIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2024
HEARNE I ENTERPRISES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2024
BLAKE, GARYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2024
BLAKE, MALISAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2024
PENNINGTON, HAROLDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2024
WILLIG, ZACHARYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2024
HONOR X ENTERPRISES, LLCOrganizationADP OF THE SNFsince 07/16/2025
GRILLO, KELLYIndividualADP OF THE SNFsince 10/01/2024

CMS files one row per role, so the 28 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$4.4M
Net patient revenuemost recent cost report
-22.7%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 67%Medicare 9%Other / private 24%

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

$290per resident / day
operating cost
$8,805per month
≈ monthly operating cost
$236per 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 676385. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, 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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