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Hico Nursing and Rehabilitation

712 North Railroad Avenue, Hico, TX 76457 · For profit - Limited Liability company · 80 certified beds · (254) 796-2111 Medicare & Medicaid certified

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Abuse/neglect citations on record (F0600, F0607) — most recent Mar 20243 immediate-jeopardy citations$31,552 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 abuse, neglect, or exploitation citations (F0600, F0607) — most recent Mar 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 3 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $31,552 in federal fines (most recent 2024-03-07)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor

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.

2/5
CMS overall
2 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 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 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
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
775 Harbin Dr · (833) 773-3001 · Call to confirm hours
Pharmacy
320 W 1st St · (254) 796-4271 · Call to confirm hours
Grocery
117 S Pecan St · (254) 796-4125 · Call to confirm hours
Park
City of Hico's Bosque River RV Park, 500 S Elm St · (254) 796-4620 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 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 rating2★
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 increased12.2%15.8%15.4%better
Long-stay residents who lose too much weight2.7%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.1%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 injury4.7%3.3%3.3%worse
Long-stay residents whose ability to walk worsened4.5%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication29.5%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine97.1%98.0%95.3%typical
Long-stay residents with pressure ulcers7.3%3.8%4.7%worse
Long-stay residents with worsening bladder/bowel control12.5%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table16.4%9.6%17.1%typical
Short-stay residents who newly got an antipsychotic medication2.6%1.5%1.4%worse
Long-stay hospitalizations per 1,000 resident days1.352.171.67better
Long-stay outpatient ER visits per 1,000 resident days0.862.061.80better

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.

10.4%U.S. median 10.7%
Went back to hospital
0.41U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 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 SNF10.4%CMS range 6.8–17.410.7%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 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 — 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 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 SNFs1.131.02Oct 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

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

Inspection trend

0
deficiencies at the latest standard inspection (2025-12-03)
6
at the previous standard inspection (2024-09-12)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 13 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · K2024-03-07 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    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, interview and record review, the facility failed to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation; the facility failed to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress for two (Resident #1, Resident #2) of five residents reviewed for neglect. The facility failed to: 1. ensure Resident #1's pain in her arm and hip was addressed after a fall on [DATE] by providing her prescribed tramadol which had run out and hospice nurse reported constant pain in left forearm 2. ensure Resident #1's neuro checks were completed and documented after a fall [DATE] in which she hit her head and displayed an increase in confusion 3. ensure Resident #1's x-rays were performed in a timely manner after a fall on [DATE] after which she complained of pain and x-rays were not performed until [DATE] 4. ensure Resident #2's pain was addressed by providing his prescribed…

    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 · K2024-03-07 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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 it developed and implemented written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for two (Resident #1, Resident #2) of five residents reviewed for neglect. The facility failed to implement its policies and procedures that were designed to prevent abuse, neglect and exploitation by failing to: 1. ensure Resident #1's pain in her arm and hip was addressed after a fall on [DATE] by providing her prescribed tramadol which had run out and hospice nurse reported constant pain in left forearm 2. ensure Resident #1's neuro checks were completed and documented after a fall [DATE] in which she hit her head and displayed an increase in confusion 3. ensure Resident #1's x-rays were performed in a timely manner after a fall on [DATE] after which she complained of pain and x-rays were not performed until [DATE] 4. ensure Resident #2's pain was addressed…

    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 · K2024-03-07 · tag F0697 — failed to manage pain — pattern
    Provide safe, appropriate pain management for a resident who requires such 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 observation, interview and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #1, Resident #2) of five residents reviewed for pain. The facility failed to: 1. ensure Resident #1's prescribed tramadol was in the facility and provided to Resident #1 for her pain after Resident #1 suffered a fall on [DATE] around 5:47 am and reported constant pain in her left arm and had a visible hematoma (swollen knot) on her right forehead. 2. ensure Resident #2's prescribed hydrocodone was in the facility and available to Resident #2 for 3 days which led to pain that went as high as a 9, especially at night, which caused sleep loss, and pain that averaged a 6 for the duration of the time his medication was unavailable An immediate jeopardy situation was identified on [DATE]. The IJ template 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 · D2025-05-14 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual 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 observations of Resident #2 plate in the room, interviews with staff, and record reviews, the facility failed to ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs for Resident #2 (1 of 1 Resident reviewed). The facility failed to follow the care plan and provide Resident #2 with a mechanically soft diet that he could eat. This could cause the resident to experience unplanned weight loss due to inability to eat properly. The facility failed to prepare a textured diet to the consistency required for Resident #2. The findings included: Record review of Resident #2's admission Record, dated 05/14/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #2's Medical Diagnosis EMR tab, accessed on 05/14/2025, reflected Resident #2 had diagnoses which include ; type 2 diabetes mellitus with hyperglycemia. Record review of Resident #2's care plan undated and accessed 05/14/2025, reflected 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 · Dcited before2025-02-18 · 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 interviews and record review, the facility failed to consult with the resident's physician when there is a significant change in the resident's physical, mental, or psychosocial status, for 1 of 7 residents (Resident #1) reviewed for changes in condition. The facility failed to notify Resident #1's mental health primary care provider (MHNP) when there was a change of condition in behaviors after an incident with Resident #1 having unsolicited sexual advances/behaviors toward another resident on 01/08/25. This failure could place residents at risk of not having their physicians notified of changes resulting in a delay in decision making for medical interventions. Findings: Review of Resident #1's face sheet dated 02/18/25 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included adrenocortical insufficiency (a condition in which the adrenal glands do not produce enough hormones such as cortisol and aldosterone), unspecified psychosis (mental health condition…

    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 before2025-02-18 · 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 of the resident that meet professional standards of quality care within 48 hours of the resident's admission for 1 of 7 residents (Resident #2) reviewed for baseline care plans. The facility failed to include Resident #2's fall history/fall risks in her baseline care plan. This failure could result in residents not receiving needed care and treatment. Findings Included: Review of Resident #2's face sheet dated 02/18/25 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain (progressive decline in cognitive function that occurs with aging), anxiety disorder (mental health condition characterized by repeated episodes of sudden feelings of intense anxiety, fear, or terror), restlessness (feeling of unease, agitation, or inability to sit…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs 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 1 of 7 residents (Resident #1) reviewed for care plans in that: The facility failed to ensure that Resident #1's newly identified sexual behaviors were documented in his care plan with interventions after an incident with Resident #1 having unsolicited sexual advances/behaviors toward another resident on 01/08/25. The facility's failure placed residents requiring care at risk of not having their individual needs met, not receiving necessary care and services, and not having continuity of care. Findings included: Review of Resident #1's face sheet dated 02/18/25 reflected 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-12 · 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 use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 2 of 90 days (FY Quarter 3 2024 - April 1 - June 30) reviewed for RN coverage. The facility failed to ensure they had an RN on duty on for 2 days: 06/08/24 and 06/09/24. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: Review of the daily staffing for 06/08/24 reflected zero hours worked by an RN on 06/08/24. Review of the daily staffing for 06/09/24 reflected zero hours worked by an RN on 06/09/24. In an interview on 09/12/24 at 11:38 AM, the DON stated there was one weekend when she did not have RN coverage for 8 hours a day in the facility. She stated she had not had an RN that she could have hired at the time and there were not any RN's available through agency. She stated she worked many hours and a lot of days herself to cover the RN position when she was supposed to be off on the weekends. She stated she also used agency when they had an 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 · F2024-09-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen: 1. The facility failed to label and date food and dry goods in a manner that identified the product and/or its use-by or discard date. 2. The facility failed to clean and sanitize the internal components of the ice machine. 3. The facility failed to properly discard food products which were expired or contaminated with mold. 4. The facility failed to store food in a manner that would prevent deterioration or contamination of the food, including growth from microorganisms. 5. The facility failed to store food in a manner that would maintain the look, taste, and integrity of the food. 6. The facility failed to clean and maintain kitchen equipment in a manner to prevent contamination. This failure placed residents at risk of food contamination and foodborne illness. Findings include: Observation of the kitchen on September 10, 2024, at 9:17 AM, revealed a Monthly Ice…

    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 · D2024-09-12 · 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 ensure residents had the right to be treated with respect and dignity for 1 of 6 residents (Resident #35) residents reviewed for dignity, in that:. Resident # 35 was left alone in her room with the door shut with food covering the front of her blouse. This failure placed residents at risk of not being treated with dignity. Findings included: Record review of Resident #35's undated admission record reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of Hemiplegia and Hemiparesis following a Cerebral Infarction Affecting the Right Dominant Side (paralysis of the right extremities after a stroke), Aphasia (difficulty with communication or speaking), Anxiety, and Conversion Disorder (a psychiatric condition) with seizures. Record review of Resident #35's care plan dated 08/15/2023 revised on 09/05/2024 reflected resident #35 had impaired cognitive function, impaired thought processes, and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-12 · 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 ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 1 of 6 residents (Resident #35) who were reviewed for accommodation of needs. The facility failed to ensure Residents #35's call light was placed within their reach. This failure could place dependent residents at risk of injuries and unmet needs. Findings included: Record review of Resident #35's undated admission record reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of Hemiplegia and Hemiparesis following a Cerebral Infarction Affecting the Right Dominant Side (paralysis of the right extremities after a stroke), Aphasia (difficulty with communication or speaking), Anxiety, and Conversion Disorder (a psychiatric condition) with seizures. Record review of Resident #35's care plan dated 08/15/2023 revised on 09/05/2024 reflected resident #35 had impaired…

    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 · D2024-09-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents are given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs) for 2 of 6 residents (Resident #14 and Resident #35 ) reviewed for ADL abilities, in that:. 1) Resident #14 appeared disheveled, had ground meat covering the front of her blouse after her meal covered up with her blanket in her wheelchair 2 hours after lunch. 2) Resident #35 was lying in a soiled bed with a brown smear approximately 12 inches by 3 inches on bed sheet. This deficient practice could place residents who required assistance at risk for not receiving care and services to meet their needs and avoid ADL decline. Findings included: 1) Record review of Resident #14's undated admission record reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of occlusion and Stenosis of bilateral carotid arteries (a clogging of the arteries),…

    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 · D2024-09-12 · 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 1 of 4 residents (Resident #35) reviewed for infection control . CNA C failed to wash or sanitize his hands while going from a dirty to clean surface while performing incontinent care for Resident #35. These deficient practices could place residents at risk for cross contamination and the spread of infection. Findings include: Record review of Resident #35's face sheet, dated 09/12/24, reflected a [AGE] year-old female with an admission date of 08/12/23. Resident #35 had diagnoses which included dysphagia (difficulty in swallowing), anxiety (an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events), pneumonia (an inflammatory condition of 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · Dcited before2024-03-07 · 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 notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of five residents reviewed for changes in condition, in that: The facility failed to notify Resident #1's RP (FM) after she experienced a fall on 01/14/24 at 5:47 am which resulted in the resident sustaining a bump to her head and a complaint of pain to her hip and leg. This failure placed residents at risk of a delay in treatment and their responsible party not being informed and involved in care decisions. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including syncope (fainting due to a decrease in blood flow to the brain), glaucoma (a condition where the eye's optic nerve is damaged), and abnormal brain scan. Review of Resident #1's Resident Information sheet in her admission packet, dated 12/13/23,…

    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 · D2024-03-07 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect resulted in bodily injury, to other officials (including the State Agency) for one (Resident #1) of five residents reviewed for abuse, neglect, and misappropriation of property, in that: The facility failed to: -Report to the State Agency (SA) within two hours after Resident #1 had a fall on 01/14/24 at 5:57 am and the subsequent x-ray results reflected a possible fracture to her left femur. This failure could place residents at risk of not having injuries related to abuse, neglect, reported. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including syncope (fainting due to 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-07 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident and failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications for 2 (fridge and Hall 2) of 3 medication locations that were reviewed for pharmacy services, failed to reconcile narcotic sheets, and failed to ensure medications were given to residents within the prescribed times. The facility failed to: 1. ensure narcotic sheets were filled out at shift change 2. reconciliation of narcotic sheets compared to MAR Resident #1 to ensure every narcotic that was signed out for Resident #1 was administered and documented as administered in the MAR 3. ensure the safe and timely administration of medications by RN A and Former Employee These failures could place the residents at risk 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-11-01 · tag F0837 — widespread
    Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
    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 the governing body, or designated persons functioning as a governing body, that was legally responsible for establishing and implementing policies regarding management and operation of the facility appointed an Administrator who was licensed by the State, responsible for management of the facility and reports to and was accountable to the governing body. The governing body did not appoint a licensed Nursing Home Administrator who was licensed by the State and had been without an Administrator since 7/15/2023. This deficient practice could have resulted in the facility not being managed in a responsible manner, which could affect the health and safety of all residents and risk of their needs not being met. Findings Include: Observation on 11/1/23 at 11:00 AM, during a facility walkthrough revealed no facility Administrator (AD) license was posted. During an interview with the Director of Nursing (DON) on 11/1/2023 at 10:55 AM, she stated the facility did not currently have an Administrator (AD) and…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-19 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure the pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, in that. -medication room with OTC products contained two bottles of expired medication. This failure had the potential to place residents who receive medications from Medication Rooms at risk for not receiving the intended therapeutic benefit of their medication. The findings include: Observation of OTC (over the counter) Medication Room at 11:40 AM on 07/18/23 revealed the following: 2 bottles- Gas Ban (Simethicone 80 mg PO)- expired 06/2023 In an interview with RN A at 11:45 AM on 07/18/23, she stated that she was unaware of where expired medications were stored. RN A stated the DON was responsible for getting rid of medications. RN A stated that since she started working at the facility in January , she was not trained on medication storage of expired medication. RN A stated that if residents were given…

    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 · E2023-07-19 · 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 achieve a medication error rates are not 5 percent or greater. There were 22 errors out of 30 opportunities, resulting in a 73 percent medication error involving 4 of 5 residents. The facility were deficient in the following areas: 1. LVN A Failed to provide medication to Resident # 28. 2. RN A Failed to administer medications within 1 hour before or after of physician's order for resident #17 and # 36 3. RN A failed to provide Dilantin according to physician orders to Resident # 05 Failure to achieve medication error rate below 5 percent can lead to potential outcome of residents at the facility not being adequately cared for. The findings included: Resident # 28 Record review of Resident #28's face sheet dated 07/19/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included altered mental status, unspecified symptoms and signs involving cognitive functions and awareness, pain in both wrist, pain in both joints 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-19 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were free of significant medication errors for one (Resident #05) of five residents reviewed for significant medication errors in that:. RN A failed to administer the correct dose of Dilantin 125mg/ 5ml to Resident #05 according to physician's order. This deficient practice failure could affect residents who were receiving Dilantin by placing them at risk of confusion, extreme lethargy(tiredness), and coma. Based on observation, interview, and record review the facility failed to ensure residents were free of significant medication errors for one (Resident #5) of five residents reviewed for significant medication errors in that: RN A failed to administer the correct dose of Dilantin 125mg/ 5ml to Resident #5 according to physician's order. This failure could affect residents who were receiving Dilantin by placing them at risk of confusion, extreme lethargy(tiredness), and coma. The findings include: Record review of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-19 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility is free of pest and rodents in that : The facility failed to ensure the facility was free from flies, crickets, and grasshoppers. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life. Findings Included: Observation on 07/18/23 at 12:00PM of the Dining hall, Hallways, and the Restrooms in the hallways, revealed there were dozens of crickets and grasshoppers roaming around. Observation of the kitchen on 07/18/23 at 2:00PM revealed, there were flies circling around in the kitchen and landing on various food products. There were crickets and grasshoppers on the floor on various locations. Observation of Resident # 35's room on 07/19/23 at 10:46 AM revealed, there were several crickets and grasshoppers on the floors. Record review of Resident #35's face sheet, dated 07/19/23, reflected an admission date…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-19 · 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 within 48 hours of resident's admission that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 5 residents (Resident #90) reviewed for baseline care plan. The facility failed to ensure Resident #90's baseline care plan or comprehensive care plan that include the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of her admission. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings were: Record review of Resident #90s face sheet, dated 07/17/23, reflected an admission date of 07/14/23 with diagnoses that included Congestive Heart Failure (low functioning heart),…

    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
  • No harm found · C2023-07-19 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    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 post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility for one of one facility. The facility failed to ensure the survey result from the previous recertification survey was readily available. This failure could place residents at risk of not being able to fully exercise their rights or have them exercised on their behalf by members of the community. Findings included: Record review of ASPEN Central Office reflected the most recent annual recertification and re-licensure survey took place on 06/03/2022. Observation on 07/17/23 at 12:30 PM revealed that there was no state survey result available at the facility in a place readily accessible to residents and family members. Observation and interview on 07/17/23 at 1:00PM, when the investigator requested for the most recent survey result folder for the residents, the DON stated the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“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

$31,552 in federal fines across 1 penalty.

  • $31,552 — penalty dated 2024-03-07

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

Part of a chain

This home belongs to CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY — 9 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 2 of 52.8-0.8 vs chain
Health inspection 2 of 52.9-0.9 vs chain
Staffing 1 of 52.1-1.1 vs chain
Quality measures 5 of 53.4+1.6 vs chain
The other 8 homes this chain runs (chain average 2.8★, per CMS)

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 / managerTypeRoleSince
ELLIS, RONALDIndividualW-2 MANAGING EMPLOYEEsince 04/01/2022
BYROM, DAVIDIndividualCORPORATE DIRECTORsince 04/01/2022
CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITYOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2022
TICKNOR ENTERPRISES HICO, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2022
TICKNOR, GREGORYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2022

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

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

Follow the money — this home’s finances

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

$3.0M
Net patient revenuemost recent cost report
-1.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 59%Medicare 4%Other / private 37%

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

$219per resident / day
operating cost
$6,654per 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 675468. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-03, 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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