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Community Care Center of Hondo

2001 Ave E, Hondo, TX 78861 · For profit - Individual · 75 certified beds · (830) 426-3087 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Nov 20233 immediate-jeopardy citations$19,096 in federal fines
Insights

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

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2023
  • inspectors cited 3 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $19,096 in federal fines (most recent 2025-04-26)
  • 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 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
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1501 Houston St · (830) 538-3550 · Call to confirm hours
Pharmacy
109 22nd St · (830) 426-3305 · Call to confirm hours
Grocery
Tetco1.7 mi
105 19th St · (830) 426-8100 · Call to confirm hours
Park
(830) 426-3378 · Typically dawn to dusk
Place of worship
602 16th St · (830) 998-5909

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 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased11.2%15.8%15.4%better
Long-stay residents who lose too much weight2.6%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 symptoms5.1%2.4%6.5%worse 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 injury8.3%3.3%3.3%worse
Long-stay residents whose ability to walk worsened1.3%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication25.1%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers2.0%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control6.3%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table8.6%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents rehospitalized after admission25.7%25.7%22.6%worse
Short-stay residents with an outpatient ER visit11.6%12.3%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.962.171.67worse
Long-stay outpatient ER visits per 1,000 resident days3.732.061.80worse

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.

9.9%U.S. median 10.7%
Went back to hospital
0.59U.S. median 0.31
Therapy hours / resident / day
0.30hours / resident / day
Physical therapy
0.29hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.59 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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 SNF9.9%CMS range 6.4–13.810.7%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 identified86.4%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 stay9.1%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 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 SNFs1.621.02Oct 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

9
deficiencies at the latest standard inspection (2025-09-12)
3
at the previous standard inspection (2024-08-16)

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.

22 citations, most serious first. The 13 most serious are shown; the remaining 9 are one tap away and print in full.

  • Immediate jeopardy · J2025-04-26 · 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 observations, interviews and record review failed to ensure the resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 residents (Resident #1) reviewed for accidents and supervision, in that: Resident #1 eloped on 11/3/2024 out of facility and was across a 35 per mile street, at store near gas pumps, near a highway, that was 40 miles per hour. On 11/2/2024 Resident #1 attempted to elope, before a nurse stopped Resident #1 from going outside. An IJ was identified on 4/25/2025. The IJ template was provided to the facility on 4/25/2025 at 6:41 PM. While the IJ was removed on 4/26/2025 at 7:53 PM. The facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not an immediate jeopardy due to facility's need to evaluate the plan of removal. This failure could place residents at risk of severe injury or…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Kcited before2023-11-14 · 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 the facility was free of pests for 5 of 6 residents (Resident #1, #2, #3, #5, and #6), in that: 1. The facility failed ensure Resident #1's room was free from flies. Resident #1 was hospitalized on [DATE] for maggot infestation around the tracheostomy and acute on chronic respiratory failure. Resident #1's stoma was suctioned around the trach until it was cleared of all maggots. A bronchoscopy was performed and cleared clots. Resident #1 was admitted to ICU for continued mechanical ventilation. 2. Resident #3, and Resident #5 had a flies in their room as they ate their breakfast and lunch tray on 11/10/2023. 3. Resident #6 had a fly on his shirt while he was eating his noon meal in the dining room on 11/11/2023. 4. Flies were observed in the hallway on A Wing and B Wing on 11/13/2023. An IJ was identified on 11/12/2023. The IJ template was provided to the facility on [DATE] at 3:59 p.m While 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2023-11-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Resident #1) reviewed for neglect, in that: The facility failed to prevent Resident #1 from having maggots in his tracheostomy site, who was hospitalized on [DATE] for maggot infestation around the tracheostomy and acute on chronic respiratory failure. Resident #1's stoma was suctioned around the trach until it was cleared of all maggots. A bronchoscopy was performed and cleared clots. Resident #1 was admitted to ICU for continued mechanical ventilation. An IJ was identified on 11/12/2023. The IJ template was provided to the facility on [DATE] at 3:59 p.m While the IJ was removed on 11/14/2023 at 3:18 p.m., the facility remained out of compliance at a scope of isolation and severity of actual harm with a potential for more than minimal harm due to facility's need to evaluate the effectiveness of their…

    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 · F2025-09-12 · tag F0576 — widespread
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility or the resident through a means other than a postal service for 2 of 8 residents (confidential residents) reviewed for resident rights.The facility failed to ensure staff distributed mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life.The findings included: During a confidential resident group meeting on 9/10/25 at 10:00 a.m., 2 of 8 members from the group meeting stated they did not receive mail on Saturdays because the Front Office Staff didn't work on Saturdays. The residents stated since the front office was locked, the mail delivered on Saturday was held in the front office and did not get delivered until the following Monday. Residents stated, the BOM collected the mail, sorted it, and then gave the mail to the Activity Director who then delivered the mail with the help…

    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 · E2025-09-12 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    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 observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for ten of ten residents (Residents #4, #15, #19, #25, #27, #29, #33, #34, #36 and #37) reviewed for food and nutrition services.The facility failed to ensure the glazed lemon cake served for the lunch meal on 09/09/2025 was pureed to the correct consistency as required for Residents #4, #15, #19, #25, #27, #29, #33, #34, #36 and #37 who were ordered a pureed diet.This deficient practice could place residents at risk of choking, poor intake, and/or weight loss. The findings included: Record review of Resident #19's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #19 had diagnoses which included peripheral autonomic neuropathy (a condition that affects the nerves that control involuntary bodily functions, such as digestion, heart rate, sweating, and urination); vascular dementia…

    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 before2025-09-12 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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 bedrooms measured at least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet in single resident rooms for 4 of 35 multiple occupancy resident rooms (#A5, #A6, #A9, and #A11) reviewed for physical environment. The facility failed to ensure rooms #A5, #A6, #A9, and #A11, which were multiple occupancy resident rooms, provided a minimum of 80 square feet per resident. This deficient practice could place residents at risk of inadequate space for activities of daily living in their rooms.The findings included:Observation on 9/10/25 at 4:55 p.m. revealed the measurement of rooms designated for three residents were as follows:- room #A5 measured 216.8 sq. ft. (72.6 sq. ft. per resident) with two residents residing in the room- room #A6 measured 220.4 sq. ft. (73.3 sq. ft. per resident) with no residents residing in the room- room #A9 measured 228.7 sq. ft. (76.2 sq. ft. per resident) with one resident residing in the room - room #A11 measured 226 sq. ft. (75.3 sq. ft. per…

    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 · Past Non-Compliance
  • Potential for harm · Dcited before2025-09-12 · 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 treat each resident with dignity and respect in a manner and environment that enhances his and her quality of life for 1 (Resident #2) of 8 residents reviewed, in that: CNA C referred to Resident #2's brief during catheter care as a diaper.The facility failed to ensure RN B provided privacy to Resident #1 when performing tracheostomy care (a surgical opening made through the front of the neck into the windpipe used to help a person breathe when the normal route through the mouth, nose, or throat is blocked or impaired). This deficient practice could affect residents at the facility who receive assistance with care and could place them at-risk for diminished quality of life, loss of dignity, and low self-esteem. The findings were: 1.Record review of Resident #2's admission record, dated 9/17/25, revealed an initial admission date of 11/24/23 and a readmission date of 11/25/24 with diagnoses that included pneumonia (an infection that…

    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 · D2025-09-12 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure the residents had the right to formulate an advanced directive) for 1 (Resident #4) of 8 residents reviewed for right to formulate advance directive. 1. The facility failed to ensure Resident #4's OOH DNR was incomplete and not able to be used in emergency situations. This failure could affect any residents who have medical records and could result in misinformation about professional care provided.Findings included: 1. Record review of Resident #4's admission Record, dated [DATE], revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including hypo-osmolality (lower than normal concentration of solutes in the blood) and hyponatremia (low sodium levels), type 2 diabetes mellitus without complications, muscle wasting and atrophy (muscle loss), muscle weakness, wedge compression fracture of T7-T8 (thoracic region- part of the body surrounded by the ribs, located between the neck and the waist)…

    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 · D2025-09-12 · 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 observation, interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 13 residents (Residents #1 and #19) reviewed for accuracy.1. The facility failed to ensure Resident #1's quarterly MDS assessment, dated 6/25/25 accurately reflected the resident's use of insulin.2. The facility failed to accurately document Resident #19's dental status on the resident's annual assessment dated [DATE].These failures could place residents at risk for inadequate care due to inaccurate assessments. The findings included: 1. Record review of Resident #1's face sheet dated 9/11/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included morbid obesity (extremely overweight), hyperlipidemia (abnormally high levels of fat in the blood), hypertension (high blood pressure), heart failure, and chronic kidney failure (long term condition in which the kidneys gradually lose their ability to filter…

    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 · D2025-09-12 · 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, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 2 residents (Resident #1) reviewed for oxygen therapy:Resident #1's oxygen concentrator filter was covered in a thick white/gray substance.This failure could affect residents who received respiratory therapy and put them at risk for inadequate or inappropriate amounts of oxygen delivery. The findings included:Record review of Resident #1's face sheet dated 9/11/25 revealed a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included major depressive disorder (mental health condition characterized by a persistent and intense feeling of sadness or loss of interest in activities), pneumonia (infection of the lungs that causes…

    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 · D2025-09-12 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (A wing medication cart) and 1 of 2 medication (B wing) storage rooms reviewed for medication storage. 1. The facility failed to ensure Resident #1's metolazone (diuretic that treats fluid retention) had a change direction sticker placed on the package. 2. The facility failed to ensure the B wing emergency cart did not contain expired supplies. These deficient practice could place residents at risk of medication misuse and diversion.1. Record review of Resident #1's physician orders, dated [DATE], revealed an order for metolazone oral tablet 5 mg, give 1 tablet by mouth one time a day every Thursday related to heart failure, with an order date of [DATE], a start date of [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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-12 · 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 prevent and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 of 4 residents (Resident #21 and Resident #41) reviewed for infection control.The facility failed to ensure RN B wore gloves when picking up Resident #21's urostomy tube (surgical procedure that creates an opening, stoma, in the abdominal wall to divert urine away from the bladder and drains into a collection bag) off the floor.The facility failed to ensure RN B wore proper PPE while providing wound care to Resident #41.These deficient practices could place residents at risk for cross contamination and infection.The findings included:1. Record review of Resident #21's face sheet dated 9/9/25 revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included gross hematuria…

    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 · E2024-08-16 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. -Container of Thick-it had a scoop stored inside container -Two 5-gallon clear food storage containers with dry cereal did not have a label and was not dated. These failures could place residents at risk of food borne illnesses. Findings were: Observation of the facilities kitchen on 08/13/2024 at 9:08 AM revealed a clear container labeled Thick-it contained a scoop in it. Observation of the facility's dry storage in the kitchen on 08/15/2024 at 11:18 AM revealed two clear 5-gallon food storage containers each filled with dry cereal were unlabeled and not dated. Interview with Dietary Manager on 08/15/2024 at 11:48 AM revealed the containers with dry cereal were filled that day and she forgot to label the container. Dietary Manager stated it was the responsibility of all staff to label foods when they are opened. Dietary Manager stated by not labeling open foods it increased 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
Show the remaining 9 citations
  • Potential for harm · D2024-08-16 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's right to be treated with respect and dignity for 1 (Resident #53) of 25 residents reviewed, in that: Resident #25 was referred to as a feeder within her clinical record. This deficient practice could cause psychosocial harm due to feelings of embarrassment and loss of dignity. The findings were: Record review of Resident #53's face sheet, dated 08/14/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: altered mental status, dysphagia oral phase, and unspecified dementia. Record review of Resident #53's quarterly MDS assessment, dated 06/21/2024, revealed a BIMS score of 04 which indicated severe cognitive impairment. Further review revealed Resident #53 required assistance to complete activities of daily living, including eating. Record review of Resident #53's care plan, edited 07/09/2024, revealed, [Resident #53] is at risk for nutritional impairment [related to] receiving therapeutic…

    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 · Fcited before2023-07-21 · tag F0925 — failed to control pests — widespread
    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 observations, interviews, and record reviews, the facility failed to maintain an effective pest control program for 1 of 28 rooms and 1 and 1 kitchen reviewed for pests, in that: The facility failed to ensure the pest control program was effective in all areas of the facility. 1. Freezer 2 had one, live, three-centimeter roach and one, live, one-centimeter ant crawling inside the lower compartment. 2. Fridge 3 had two, live, one-centimeter ants crawling inside the lower compartment of the unit. 3. Fridge 2 had two, unmoving, one-centimeter ants inside the lower compartment of the unit. 4. room [ROOM NUMBER] had a live four-inch roach crawling along the wall. This failure could affect residents by increasing their risk of exposure to pests, vector-borne diseases, and infections. The findings included: Observation and interview on 07/19/2023 at 3:22 PM, revealed a single three-centimeter roach and a single one-centimeter ant crawling inside Freezer 2. The DM stated That's a roach and an ant when asked to…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-21 · 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 in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for 2 of 24 residents (Resident #36) reviewed for resident rights, in that: Residents #36 and #148 were told they could not flush toilet paper down the toilet of their shared bathroom and must dispose of soiled toilet paper in the receptacle. This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth. The findings included: Record review of Resident #36's face sheet, dated 07/21/2023, reflected a [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of acute on chronic right heart failure. Record review of Resident #36's annual MDS, dated [DATE], revealed a BIMS of 12 which indicated moderate impairment. Record review of Resident #36's comprehensive person-centered care plan, dated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-21 · tag F0563 — failed to protect the right to visitors — isolated
    Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
    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 residents have the right to receive visitors of his or her choosing at the time of his or her choosing for 1 of 6 (Resident #31) residents reviewed for resident rights. The facility failed to ensure Resident #31 had the right to receive visitors inside the facility. This failure placed residents at risk of isolation, decreased emotional well being and diminished quality of life. The findings included: Record review of Resident #31's face sheet, dated 7/20/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), pneumonia (an infection that inflames the air sacs in one or both lungs), hypertension (high blood pressure), muscle wasting and atrophy (wasting [thinning] or loss of muscle tissue), end stage renal disease and depression. Record review of Resident…

    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 · D2023-07-21 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #44) reviewed for pharmacy services in that: The facility failed to accurately transcribe and clarify Resident #44's prescription for levofloxacin (an antibiotic) into the electronic medication administration record. This deficient practice could affect residents who received medications and place them at risk for adverse reaction and/or a decline in health. The findings included: Record review of Resident #44's face sheet, dated 7/21/23 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), pneumonia, dysphagia, oropharyngeal phase (difficulty…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-21 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (excessive dose and duplicative therapy) for 1 of 6 residents (Resident #98) reviewed for unnecessary medications in that: The facility failed to address the pharmacist consultant's recommendation for the routine use of antibiotic therapy for Resident #98. This failure could place residents at risk for adverse drug reactions and receiving unnecessary medications. The findings included: Record review of Resident #98's face sheet, dated 7/21/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included pneumonia, pain, acute candidiasis of vulva and vagina (yeast infection), hypertension (high blood pressure), urinary tract infection, dementia without behavioral disturbance and long-term drug therapy. Record review of Resident #98's most recent quarterly MDS assessment, dated 6/18/23 revealed the resident was moderately cognitively impaired 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 · Dcited before2023-07-21 · 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 observations, interviews, and record reviews, 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 2 residents (Resident #34) reviewed for infection control practices, in that: CNA C and CNA D did not utilize appropriate hand hygiene during incontinent/catheter care to Resident #34. These failures could place residents who required incontinent/catheter care at risk for infection or a decline in health. The findings included: Record review of Resident #34's face sheet, dated 7/21/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included cerebral infarction (a stroke, a disrupted blood flow to the brain due to problems with the blood vessels that supply it), enterocolitis (inflammation of the colon) due to clostridium difficile (a bacteria…

    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
  • No harm found · Bcited before2024-08-16 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure that 4 of 35 multiple occupancy resident rooms (#A5, #A6, #A9, and #A11) provided a minimum of 80 square (sq.) feet (ft.) per resident. This deficient practice could place residents at risk of inadequate space for activities of daily living in their rooms. The findings were: Observation on 08/14/2024 beginning at 11:00 a.m. and measurement of rooms designated for three residents revealed room #A5 measured 217 sq. ft. (72.3 sq. ft. per resident) with one resident residing in the room, room #A6 measured 220.5 sq. ft. (73.6 sq. ft. per resident) with no residents residing in the room, room #A9 measured 228 sq. ft. (76.0 sq. ft. per resident) with two residents residing in the room, and room #A11 measured 225 sq. ft.(75.0 sq. ft. per resident) with one resident residing in the room. Observation of resident room # A11 revealed it had 2 light fixtures and 2 call light systems visible. Interview with the Administrator on 08/15/2024 at 9:20 a.m. confirmed that four of the facility's room were below 80 square…

    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
  • No harm found · Bcited before2023-07-21 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure that 4 of 35 multiple occupancy resident rooms (#A5, #A6, #A9, and #A11) provided a minimum of 80 square (sq.) feet (ft.) per resident. This deficient practice could place residents at risk of inadequate space for activities of daily living in their rooms. The findings were: Observation on 07/19/2023 at 10:00 a.m. and measurement of rooms designated for three residents revealed room #A5 measured 217 sq. ft. (72.3 sq. ft. per resident) with one resident residing in the room, room #A6 measured 220.5 sq. ft. (73.6 sq. ft. per resident) with no residents residing in the room, room #A9 measured 228 sq. ft. (76.0 sq. ft. per resident) with two residents residing in the room, and room #A11 measured 225 sq. ft.(75.0 sq. ft. per resident) with one resident residing in the room. Observation of resident room # A11 revealed it had 2 light fixtures and 2 call light systems visible. Interview with the Administrator on 07/21/2023 at 1:30 p.m. confirmed that four of the facility's room were below 81 square feet…

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

    Environmental Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$19,096 in federal fines across 2 penalties.

  • $11,403 — penalty dated 2025-04-26
  • $7,693 — penalty dated 2023-11-14

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

Who owns this facility

Owner / managerTypeRoleSince
BAIN, WILLIAMIndividualCORPORATE OFFICERsince 05/23/2011
BELL, BILLIEIndividualCORPORATE OFFICERsince 06/03/2023
CARTER KRIEGER, LORIIndividualCORPORATE OFFICERsince 10/01/2020
FROSCH, KEVINIndividualCORPORATE OFFICERsince 07/07/2010
HARDT, TIMOTHYIndividualCORPORATE OFFICERsince 05/23/2011
JOHNSON, ROBERTIndividualCORPORATE OFFICERsince 02/01/2017
WHITE, LYNNIndividualCORPORATE OFFICERsince 02/01/2017
WINDROW, ZACHARYIndividualCORPORATE OFFICERsince 11/26/2012
WINKLER, JUDYIndividualCORPORATE OFFICERsince 11/26/2012
YOUNG, CARLTONIndividualCORPORATE OFFICERsince 11/26/2012
HONDO SNF OPERATIONS, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2024
RAMOS, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2024
BRUCE, LELANDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/04/2026
GAYTAN, LUCYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/04/2026
HIXSON, BROOKEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/04/2026
THUET, DANIELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/04/2026
APOLINAR, ARTUROIndividualADP OF THE SNFsince 09/01/2024
WINDROW, MATTHEWIndividualADP OF THE SNFsince 09/01/2024

CMS files one row per role, so the 19 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$5.1M
Net patient revenuemost recent cost report
+21.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 67%Medicare 15%Other / private 17%

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

$211per resident / day
operating cost
$6,427per month
≈ monthly operating cost
$268per 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 455676. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-12, 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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