Avir at Houston
2310 S Eldridge Pkwy, Houston, TX 77077 · For profit - Corporation · 148 certified beds · (281) 558-3900 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors cited 6 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (41) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $180,218 in federal fines (most recent 2026-05-08)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 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 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 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 held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.7% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.3% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.1% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 2.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.1% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.6% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.5% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 90.9% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 11.4% | 3.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 12.7% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.8% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 77.8% | 88.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 28.1% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.4% | 12.3% | 12.0% | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
59.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 239 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 45.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 70 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.77 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 59.7%CMS range 54.0–67.3 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 8.6–14.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 45.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 41.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 32.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 94.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 96.7% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.7–10.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.08 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 148 beds and averages 72.5 residents a day — about 49% occupied, or roughly 76 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.79 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 0.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.26 hrs/resident/day on weekends vs 3.00 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 1.08 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
41 citations, most serious first. The 16 most serious are shown; the remaining 25 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-05-08 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #93) of five residents reviewed for discharges. The facility failed to safely discharge Resident #93 when she was:1. discharged home on [DATE] by EMS via stretcher, incontinent of bowel and bladder, and unable to ambulate, with no support services from home health.2. discharged without an AMA (This occurs when a patient chooses to leave a hospital or healthcare facility before the treating physician recommends discharge), discharge notice, or notice to the Ombudsman per facility policy. During less than 24 hours after Resident #93 was discharged home she urinated and defecated on herself and was unable to change her clothing and clean her body. Resident #93 was subsequently hospitalized due to CHF exacerbation (a chronic condition where the heart does not pump blood as effectively as it should,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · K2025-12-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident with pressure ulcer (injury/bedsore) is skin and tissue damage from prolonged pressure, friction, or shear) receives necessary treatment services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure ulcers from developing for 1 of 4 closed record (CR) #1 reviewed for pressure ulcers in that: 1. The facility failed to prevent the development of a pressure ulcers to CR #1's 1-left foot measuring (Length x Width x Depth) 2x2x0 centimeters (cm).2. The facility failed to prevent the development of a pressure ulcers to CR #1's right lateral ankle measuring 1x1x1 cm.3. The facility failed to prevent the development of a pressure ulcers to CR #1's 1-left hip measuring 4x4x0 cm.4. The facility failed to prevent the development of a pressure ulcers to CR #1's-sacrum/sacral (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones 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.
- Immediate jeopardy · Jcited before2024-02-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident goals and preference for 1 (Resident #81) of 1 reviewed for tracheostomy care. -LVN A failed to reconnect Resident #81's trach to oxygen after removing it to gather trach supplies. -LVN A failed to properly secure Resident #81's trach when removing the trach tie. -LVN A failed to clean Resident #81's trach stoma to prevent infection. An IJ was identified on 02/16/2024. The IJ template was provided to the facility on [DATE] at 5:44PM. While the IJ was removed on 02/19/2024 at 10:55AM, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not an immediate jeopardy because all staff had not been trained on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2024-02-20 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that the nursing staff were able to demonstrate competency in skills and techniques necessary to provide tracheostomy care for 1 (Resident #81) of 1 resident reviewed for tracheostomy care. -LVN A failed to reconnect Resident #81's trach to oxygen after removing to gather trach supplies. -LVN A failed to properly secure Resident #81's trach when removing the trach tie. -LVN A failed to clean Resident #81's trach stoma to prevent introducing micro-organism (bacteria) inside of tracheostomy. An IJ was identified on 02/16/2024. The IJ template was provided to the facility on [DATE] at 5:44PM. While the IJ was removed on 02/19/2024 at 10:55AM, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not an immediate jeopardy because all staff had not been trained on tracheostomy care. This failure has the potential to place resident(s) with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · K2023-11-08 · tag F0580 — failed to tell family and doctor about changes — patternImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for 1of 5 residents (CR#1) reviewed for physician notification. The facility failed to notify the physician of Resident #1's continued change in condition, including low blood pressure and high pulse rate, for approximately 12 hours. After approximately 12 hours Resident #1 was sent to the hospital via emergency transport and was admitted with Pneumonia, Acute Kidney Failure, and Septic Shock and was placed on life-support. An IJ was identified on 11/6/2023. The IJ template was provided to the facility on [DATE] at 4:13pm. While the IJ was removed on 11/8/2023, the facility remained out of compliance at a scope of Isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan. This failure could affect residents by placing them at…
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.
- Immediate jeopardy · K2023-11-08 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the residents' choices for 1 of 5 residents (CR# 1) reviewed for quality of care. The facility failed to ensure that CR #1 received treatment and care in accordance with professional standards of practice. The facility failed to call 911 services to transport CR#1 to a higher level of care, instead, attempted to use their non-emergency transportation to send resident to the hospital when CR #1 ' s blood pressure was extremely low and pulse extremely high. The facility failed to transfer CR #1 to the hospital in a timely manner when resident ' s vitals began to decline. The facility initially became aware of CR#1 ' s declining vitals 11/1/23 at 5:34am and 911 was called 11/2/23 at 7:00am, 24 hours after the facility was made aware of CR#1 ' s condition. An IJ was identified on 11/6/2023. The IJ template was provided to the facility on [DATE] at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-26 · tag F0655 — isolatedCreate 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 observation, 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 including initial goals based on admission orders and physician orders for 2 of 4 residents (Resident #18 and Resident #2) reviewed for comprehensive care plans. 1.The facility failed to develop a care plan and interventions to address Resident #18's two diabetic ulcers and a pressure injury in a timely manner.2.The facility failed to develop a care plan and interventions to address Resident #2's great big toe ulcer in a timely manner.These failures could place residents at risk of not having their individual, medical and functional needs identified and cause a physical decline in health.1. Record review of Resident #18's face sheet, dated 06/26/2026, reflected a [AGE] year-old female who was originally admitted to the facility on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-26 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
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 received proper treatment and care to maintain mobility and good foot health and provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 1 of 5 (Resident #2) residents reviewed for foot care .1.The facility failed to ensure Resident #2 did not have long toenails around 3 mm on the three middle bilateral toes, observed on 06/26/2026.2. The facility failed to ensure the NP recommendations made for Resident #2 to see a Podiatrist on 06/20/2026 were followed and no attempts to make a podiatry appointment were made until 06/26/2026 after State Surveyor intervention .These failures could place residents at risk of developing foot problems such as infection and hinder recovery…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-26 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed ensure that the hospice services met professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services and to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs for 1 of 4 residents (Resident #2) reviewed for hospice and personal care. The facility failed in notifying Resident #2's Hospice that Resident #2's NP recommended he see a Podiatrist for his long toenails. This failure could place residents at risk of not receiving foot care treatment in a timely manner.Record review of Resident #2's face sheet, dated 06/26/2026, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #2 had medical diagnoses which included cerebral infarction due to thrombosis of right middle cerebral artery…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that each resident receives adequate supervision for 1 (Resident #1) of 1 reviewed for supervision.The facility failed to provide supervision for Resident #1 when he eloped from the facility on 6/7/2026 between the hours of 9:15 a.m. and 9:40 a.m., when Resident #1 was found by law enforcement outside the perimeter of the facility in the grass. This failure could place all residents at risk of experiencing pain, physical, emotional distress, and possible death. Record Review of Resident #1's chart reveals he was a [AGE] year-old male with a BIMS score of 6, admitted to the facility on [DATE]. Resident #1's primary diagnosis was dehydration. He was also diagnosed with unspecified mood disorder, bipolar, major depression, hyperlipidemia, post traumatic stress disorder, and unspecified dementia. He uses a wheelchair for mobility. He was impaired on both sides, lower extremity ([NAME], knee, ankle, foot) to have functional limitation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for incontinent care. The facility failed to ensure CNA A properly cleaned Resident #1 during incontinent care when CNA A did not around Resident #1's buttocks on 06/16/2026.This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings included:Review of Resident #1's face sheet dated 6/16/26 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: cognitive communication deficit, essential primary hypertension ( high blood pressure), hyperlipidemia ( high fat in the blood), major depression disorder (causes ongoing sadness, hopelessness and loss of interest that lasts at least two weeks, it can affect sleep, energy and relationships) and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-16 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 3 residents reviewed for infection control. - The facility failed to ensure CNA A washed or sanitized her hands and performed glove changes appropriately while providing incontinence care to Resident #1 on 06/16/26. This deficient practice placed residents at risk for cross contamination and the spread of infection. Finding included: Review of Resident #1's face sheet dated 6/16/26 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: cognitive communication deficit, essential primary hypertension, ( high blood pressure), hyperlipidemia ( high fat in the blood), major depression disorder ( causes ongoing sadness, hopelessness and loss of interest…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-08 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 each resident was treated 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, recognizing each resident's individuality for 4 of 15 residents (Resident #20, Resident #59, Resident #64 and Resident #102) reviewed for resident rights. The facility failed to ensure CNA B knocked on Resident #20, and Resident #59 and Resident #64's doors when going into the residents' rooms. The facility failed to ensure Resident #102's catheter had privacy cover on it. These failures could place residents at risk of poor self-esteem and feeling like their privacy was being invaded.Findings include: 1. Record review of Resident #20's face sheet, dated 05/05/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20 had diagnoses which included metabolic encephalopathy (brain disease), hypertensive chronic kidney disease (damage to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-08 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 of 3 residents (Resident #27, Resident #73, and #85) reviewed for activities. The facility failed to provide Resident #27 with activities he was able to do, failed to offer Resident #73 activities, and failed to provide Resident #85 activities that interested him. This failure could place residents at risk for boredom, depression, and diminished quality of life. Findings include: 1.Review of Resident #27's face sheet dated 05/07/2026 reflected an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included blindness right eye category 5 (total,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-08 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure storage of drugs and biologicals used in the facility for 2 of 8 medication carts observed for medication storage and labeling. The facility failed to ensure loose medications were removed from the medication carts. This failure could place residents who received medications at risk of not receiving the intended therapeutic effect of the medication. This failure could lead to unsafe and unsecure storage of all medication to reduce, minimize loss, or diversions for all medications.Findings included: Observation on 05/07/2026 at 11:07 a.m., reflected RN B had five loose pills in her medication cart. In an interview on 05/07/2026 at 11:08 a.m., RN B reported the nurses, unit managers, DON, and pharmacy check the medication carts. She reported that the pharmacy checks the medication carts every month. She reported she notified DON and disposed of the loose medications in the sharp's container [specialized, puncture-resistant receptacle used to safely dispose of medical instruments that can cut or puncture the skin, such…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-08 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to serve food and drink that was palatable, attractive, and a safe and appetizing temperature for residents for one (1) of one (1) kitchen reviewed for food and nutrition services. The facility failed to serve warm food to residents. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life.Findings included: During an interview on 05/05/2026 at 7:01 a.m. Resident #63 stated the food was always cold when he ate in his room. Resident #63 stated that he had to ask staff to warm up his food and bring it back because he could not eat cold food because it did not taste good. During an interview on 05/05/2026 at 7:32 a.m. Resident #91 stated the food was not good and it was served cold. During an observation and interview on 05/05/2026 at 7:35 a.m. and 8:28 a.m. Resident #75 was overhead yelling from her room, where is my breakfast? Can someone bring me my breakfast? My plate is cold. Staff reheated plate and returned it. Resident #75 stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 25 citations
- Potential for harm · Ecited before2026-05-08 · tag F0880 — failed to prevent and control infections — patternProvide 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 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 4 (Resident #7, Resident #32, Resident #95 and Resident #101) of 7 residents reviewed for infection control. The facility failed to ensure CNA A wore PPE as required for Resident # 32, who was on enhanced barrier precautions. The facility failed to ensure Central Supply wore PPE as required for Resident # 95, who was on enhanced barrier precautions. The facility failed to ensure LVN D followed infection control and prevention by not cleaning the glucometer prior to and after checking Resident #101's blood sugar, and by not cleaning the insulin vial prior to withdrawing a dose. The facility failed to ensure LVN D followed the hand hygiene policy by not properly performing hand hygiene while administering insulin to 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.
- Potential for harm · D2026-05-08 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #27) of one residents reviewed for vision impairment. The facility failed to ensure Resident #27 1. Was told what food he was having for breakfast and where it was located on his tray and it was free from cellophane 2. Received large print reading materials This failure could place residents at risk of needs and accommodation being unmFindings Include: Review of Resident #27's face sheet dated 05/07/2026 reflected an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included blindness right eye category 5 (total, irreversible blindness, often defined as no light perception) and blindness left eye category 4 (represents a severe visual impairment where the best corrected visual acuity in the eye is worse than 20/200, defined as having only ability to see light rather than form). 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.
- Potential for harm · D2026-05-08 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a new resident was not admitted with mental illness unless the state mental health authority determined, based on independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission for 2 of 12 residents (Resident #35 and Resident #65) reviewed for PASRR services. The facility failed to ensure a PASRR screening was completed correctly for Resident #35 and for Resident #65. This failure could place residents at risk for not obtaining the services needed to treat their mental health diagnoses. The findings include: 1. Record review of Resident #35's face sheet, dated 05/06/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #35 had diagnoses which included bipolar (extreme mood swings), shortness of breath, dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), hypertension (high blood pressure), cerebral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-15 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 6 of 10 residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for pharmacy services.The facility failed to administer Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7's medications greater than one hour after the scheduled administration time.This failure placed residents at risk for receiving less than therapeutic benefits from medicationsFindings included:Record review of Resident #2's face sheet, dated 04/15/26, reflected Resident #2 was admitted to the facility on [DATE]. She was a [AGE] year-old female diagnosed with type 2 diabetes, orthostatic hypotension (low blood pressure when standing), peripheral vascular disease(slow peripheral blood circulation) ,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (Resident #1) reviewed for respiratory care.The facility failed to ensure Resident #1's O2 nasal cannula and water bottle changed every week as ordered by the physician.This failure placed residents at risk for respiratory infections through contamination. Findings included:Record review of Resident #1's face sheet, dated 04/14/26, reflected Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was an [AGE] year-old female diagnosed with COPD (difficulty to breath due to restricted airflow) , obstructive sleep apnea (breathing stop and start during sleep) , acute bronchiolitis (lower respiratory infection) , chronic kidney disease, dementia, major depressive disorder and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-02 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents discharge to an appropriate setting that could meet the resident's needs for 1 of 4 closed record (CR #2) reviewed for discharge in that: 1. The facility discharged CR #2 to a homeless shelter for men where he had difficulties performing his activities of daily living (ADL) and administer and store his medications. This failure could place residents at risk of unsafe discharges, sadness, fear, injury, and death.Record review of CR #2's Facesheet dated 11/11/2025 reflected a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 07/31/2025 to a private home/apartment with no home health services. CR 2#'s diagnosis included hemiplegia (paralysis or weakness of one side of the body affecting the arm, leg, or face) and hemiparesis (one-sided weakness on one side of the body, affecting the arm, leg, or face) following cerebral infarction (the death of brain tissue due to a lack of blood flow) affecting right dominant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-19 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an MDS was completed for a resident and entered MDS data into the facility's assessment software resident's assessment was completed within 7 days after completing the MDS and electronically transmit the MDS data to CMS within and 14 days after completing the MDS, and electronically transmit encoded, accurate, and complete MDS data to the CMS System for a subset of items upon a resident's transfer, reentry, discharge, and death for 1 of 4 discharged residents (CR #2 ) reviewed for encoding and transmitting resident assessments., in that: - The facility failed to complete and transmit a discharge MDS for CR #2. This failure could place discharged residents at risk of not having a proper discharge and not receiving services post discharge.Findings included: Record review of CR #2's face sheet, dated 09/21/2025, reflected a [AGE] year-old female originally admitted to the facility on [DATE] and was discharged on 09/23/2025. Her medical diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (CR #3) reviewed for incontinent care. -The facility failed to ensure CR #3 had her urine output monitored 3/14/2025 and 3/19/2025 as ordered. This failure could place residents at risk for pain, infection, injury, and hospitalization.Record review of CR #3's face sheet, dated 10/23/2025, reflected a [AGE] year-old female originally admitted to the facility on [DATE] and discharged [DATE] to a private home. Her medical conditions included an unspecified fracture of her T5-T6 vertebra (vertebra being the bones forming the backbone) due to pedestrian on foot injured in collision with car, pain, constipation, and traumatic subdural hemorrhage (brain injury caused by head trauma involving the buildup of blood in the brain) without loss of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-20 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record review the facility failed to provide, based on the preferences of each resident, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 5 of 5 confidential residents reviewed for activities. The facility failed to provide activities to meet the residents' interests on Saturdays and Sundays for 5 confidential residents. These failures placed residents at risk for decline in quality of life, social and mental psychosocial wellbeing. Findings Include: During a confidential group interview on 03/19/2025 and 10:04 a.m., with 5 confidential residents, all residents stated that there are no weekend activities. They stated that they could attend church on Sundays, but no other activities were provided. They stated that they would love to have weekend activities, as it was boring. They stated that the only time they had weekend activities was when the Activities Director was on shift during the weekend once a month. During an interview with the Activities Director on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-20 · tag F0694 — patternProvide for the safe, appropriate administration of IV fluids 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 parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 out of 7 residents (Resident # 42) reviewed who were receiving parenteral fluids. -The facility failed to change Resident # 42's PICC line (a longer catheter threaded into a larger vein near the heart) dressing every 7 days as ordered by the physician. -LVN B failed to measure Resident #42's external PICC line catheter prior to removing the old dressing to ensure that the tip of the catheter had not dislodged. -LVN B failed to properly remove Resident #42's PICC line dressing to prevent dislodgement. These failures placed resident at risk for infections, injuries, unwanted hospitalization, and decrease in quality of life. Findings: Record review of Resident #42's face sheet dated 03/19/25 revealed a [AGE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-20 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that its medication error rate was not 5 percent or greater. The medication error rate was 14 percent with 5 errors out of 35 opportunities involving 1 of 3 staff members (LVN B) and 2 of 7 residents (Resident #392, Resident #393) reviewed for medication administration. - LVN B administered 3 medications to Resident #392 via PEG tube (feeding tube) in a manner that was not in accordance with accepted professional standards and principles. She crushed the medications into a powder form in each medication cup, dissolved it in water, LVN B did not ensure she got all the medication out of the medication cup during administration. - LVN B failed to administer doxycycline monohydrate and did not follow order when she also administered antacids, vitamins or iron without waiting for 2 hours as ordered for Resident #393. This failure could place residents at risk of their medications not being administered in accordance with professional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-20 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 record review and interview, the facility failed to assess each resident annual assessment using the Annual Minimum Data Set (MDS) form specified by the state and approved by Center for Medicare and Medicaid Services (CMS) for review of 12-closed record and 1 of 5 Residents (Resident #1) reviewed for annual assessments. The facility failed to complete Resident #1's MDS Assessment within 124 days (11/08/2024 through 03/20/2025) of the previous MDS assessment. This failure could place all residents at-risk of not having their assessments completed timely. The findings included: Record review of Resident #1's Facesheet dated 03/20/2025 revealed Resident #1 was an 88-years old female who admitted to the facility on [DATE]. Resident's diagnosis included, but were not limited to unspecified dementia (group of symptoms effecting memory, thinking and social abilities), unspecified severity, without behavioral disturbance, psychotic disturbance (disassociation with reality), mood disturbance, and anxiety,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-20 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
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 assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for review of 1 of 5 Residents (Resident #1) and 12-closed records reviewed for assessments. The facility failed to complete a quarterly assessment for Resident #1 every 3 months (11/08/2024 through 03/20/2025). This failure could place residents at risk for not getting an accurate assessment and could result in lack of care. Findings include: Record review of Resident #1's Facesheet dated 03/20/2025 revealed Resident #1 was an 88-years old female who admitted to the facility on [DATE]. Review of Resident #1's last completed MDS assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 03 which indicated sever impaired cognition. Further review of Resident #1's MDS tracking record revealed the previous completed MDS was completed on 08/08/2024. The next MDS listed was a quarterly 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.
- Potential for harm · Dcited before2025-03-20 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transmit ensure an MDS was completed and electronically transmitted to the CMS System for 14 days after completion resident assessment within the required time frame for 1 of 5 (Resident #1) and 12 closed records, reviewed for data transmission in that: The facility failed to complete and transmit Resident #1's quarterly MDS. This failure could place residents at risk of not having their assessments transmitted timely and an incomplete record. Findings Include: Record review of Resident #1's Facesheet dated 03/20/2025 revealed Resident #1 was an 88-years old female who admitted to the facility on [DATE]. Record review on 03/20/2025 at 02:35 p.m., revealed that Resident #1's quarterly assessment due 02/22/2025 showed an In Progress status and had not been uploaded. During an interview on 03/20/2025 at 4:24 p.m., MDS Coordinator stated Resident #1's MDS assessment was due by 02/22/2024. She stated it was transmitted late, 03/20/2025 and it had been her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-20 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #42) of 11 residents reviewed for comprehensive care plans. - Resident # 42 was not care planned on 03/10/2025 for a PICC line insertion ordered on 03/07/25. These failure place resident at risk for infections and unwanted hospitalization. Findings included: Record review of Resident #42's face sheet dated 03/19/25 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident diagnoses included the following: sepsis (serious condition in which the body responds improperly to an infection), hypertension (elevated blood pressure), neuropathy (nerve damage), metabolic encephalopathy (when the brain is not functioning properly cause by a wide range of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-20 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 services provided by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (Resident #392) of one resident observed for gastrostomy tube feedings. The facility failed to ensure LVN B administered medication and water to Resident #392 via her gastrostomy tube (g-tube) by following physician's order These failures could place residents at risk for fluid overload weight loss, aspiration pneumonia, and abdominal discomfort. Findings included: Review of Resident #392's admission Assessment reflected she was a [AGE] year old female who was admitted to the facility on [DATE]. Her diagnoses included gastrostomy tube (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach), dysphagia (difficulty swallowing), pneumonitis ( swelling and irritation, also called inflammation, of lung tissue) due to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the necessary services to maintain grooming and personal care for 2 (Resident #195 and Resident #192) of 7 residents reviewed for ADL care, in that: - The Ffacility failed to give Resident #195 his schedule showers on Tuesday, Thursday, and Saturday on a consistent basis. - The facility failed to ensure Resident #192 was provided incontinent care in a timely manner. These failures placed residents a risk for skin break down, offensive odors, and decrease in quality of life. Findings: Resident #195 Record review of Resident #195's face sheet dated 03/20/25 revealed a [AGE] year-old female was admitted to the facility on [DATE]. Resident #195 had diagnoses included: diabetes mellitus (Body do not produce enough insulin or cannot effectively use insulin), hypertension (blood pushing against the artery walls is consistently too high) and absence of right leg below knee (surgical removal of right). Record review of Resident #195's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-20 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents were free of significant medication errors for 1 (Resident #392) of 7 residents reviewed for pharmacy services. The facility failed to ensure Resident #392 was free of significant medication errors when Resident #392, atorvastatin (medication to treat high cholesterol), Lamotrigine (medication to treat seizure), and Fluoxetine (which is an antidepressant) was administered by LVN B on 03/19/2025. LVN B failed to administer 3 medications to Resident #392 via PEG tube (feeding tube) in a manner that was not in accordance with accepted professional standards and principles. She crushed the medications into a powder form in each medication cup, dissolved it in water, LVN B did not ensure she got all the medication out of the medication cup during administration. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician. Findings included: Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-07 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the necessary services to maintain grooming and personal care for 2 (Resident #2 and Resident #1) of 7 residents reviewed for ADL care, in that: - The facility failed to ensure Resident #2 was provided personal grooming (dry patches and flaky skin) by facility staff. - The Facility failed to give Resident #1 his schedule showers on Tuesday, Saturday, and Saturday on a consistent basis. These failures placed resident a risk for skin break down, offensive odors, and decrease in quality of life. Findings: Resident #2 Record review of Resident #2's face sheet dated 03/03/25 revealed a [AGE] year-old male was admitted to the facility on [DATE]. Resident #2 had diagnoses included: human immunodeficiency virus disease (virus that damages the body's immune system.), hypertension (blood pushing against the artery walls is consistently too high) and cerebral infarction (strike that occur when blood floor to the brain is blocked). Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-07 · tag F0687 — failed to care for feet properly — patternProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for one (Resident #2) of four residents reviewed for food care. Resident #2 was not seen by a podiatrist for long, thick, and deformed toenails. This failure placed residents at risk of not receiving foot care consistent with professional standards of practice. Findings included: Record review of Resident #2's sheet dated 03/03/25 revealed a [AGE] year-old male was admitted to the facility on [DATE]. Resident #2 had diagnoses included: human immunodeficiency virus disease (virus that damages the body's immune system.), hypertension (blood pushing against the artery walls is consistently too high) and cerebral infarction (strike that occur when blood floor to the brain is blocked). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed Resident BIMS was 04 which indicated severely impaired cognition. Resident #2 depended…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-07 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were accurately documented for 1 of 5 (Resident #7) residents reviewed for accurate medical records. -LVN C and LVN D failed to document why Resident #7's Tramadol Hcl Oral Tablet 100 MG for pain every 8 hours was not given on 2/13/2025 at 2:00am and 10:00am. This failure could place residents at risk of having care provided based on inaccurate monitoring and documentation. Findings included: Record review of Resident #7's face sheet, she was a [AGE] year-old female originally admitted on [DATE] and last admitted on [DATE]. Her medical diagnoses included: encephalitis (inflammation of the brain, often due to infection) and encephalomyelitis (inflammation of the brain and spinal cord), dysphagia (difficulty swallowing), and cognitive communication deficit. She passed away on 02/13/2025. Record review of Resident #7's care plan. she had a focus area 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.
- Potential for harm · E2024-02-20 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews the facility failed to complete a performance review at least every 12 months for 2 of 5 nursing staff (CNA M, CNA N) reviewed for training. The facility did not complete a performance review at least once every 12 months on CNAs M and N. This failure could place residents at risk by being cared for by nurse aides with inadequate training and skills and not being provided the in-services needed based on these reviews. Findings included: Record review of personnel files revealed no documentation of a performance review being done to the following employees annually: -CNA M, hired on 11/26/2009 -CNA N, hired on 1/24/2020 During an interview on 02/16/2024 at 5:31pm with the Administrator, he said the facility does a general orientation for new staff but no performance review. During another interview on 02/20/2024 at 10:00 am with the Administrator, he said that the facility did not complete regular performance checks for staff and that there was not a specific policy on staff training nor performance reviews. The Administrator said he reinstated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-02-20 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that its medication error rates are not 5 percent or greater. There were 3 errors out of 36 opportunities which resulted in an 8 percent error rate involving Resident # 79 and Resident #80. -LVN A failed to administer Resident #79's omeprazole 20mg before their meal. -LVN fFailed to administer Resident #80's omeprazole 20mg before their meal. -LVN Failed to administer Resident #80 lidocaine patch 5% as ordered by the physician. These failures placed residents at risk for not receiving therapeutic benefits of their medication. Findings: Resident #79 Record review of Resident #79's face sheet dated 02/18/2024 revealed that resident was an [AGE] year old female admitted to the facility on [DATE] with diagnoses that included the following: transient cerebral ischemic attack (a brief stroke-like attack), hydrocephalus (build up of fluid within in the brain), hypertension (high blood pressure), and traumatic subdural hemorrhage (head…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure that each resident received adequate supervision for 1 (Resident # 1) of 5 residents reviewed for supervision. The facility failed to ensure Resident # 1 received supervision while in the elevator. The facility failed to monitor and supervise Resident # 1 as she was unable to operate the elevator. This failure could place residents at risk of being in an unsafe environment or serious injuries as Resident #1 was in the elevator alone for over seven minutes. Finding included: Record review of Resident # 1 admission dated 10/20/2023, revealed a [AGE] year old female with admission date of 10/20/2023 and diagnoses which include [NAME] Syndrome ( a disorder of the colon in the absence of an anatomic lesion that obstructs the flow of intestinal content, obesity (overweight), hypokalemia (blood level that is below normal), Embolism (obstruction of an artery, typically by a clot of blood or an air bubble, Thrombosis ( the formation of a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who were incontinent of bladder and bowel and unable to carry out activities of daily living (ADLs) and received necessary services to maintain personal hygiene for 3 of 3 residents reviewed for ADLs, (Resident #s 1, 2, and 3) The facility did not provide Resident #1 with incontinent care for more than 10 hours on 09/12/23 and 09/16/23. The facility did not provide Resident #2 with incontinent care for more than 10 hours on t. On 09/09/23, Resident #2 had a colostomy bag that overflowed leaving feces on the resident, resident's wheelchair, and floor. The facility did not provide Resident #3 with incontinent care for more than 10 hours on 09/14/2023, 09/15/2023 and 09/16/23. Resident #3 was incontinent of urine, required assistance with ADLs This failure could place residents who were dependent on staff for assistance with incontinence care at risk for embarrassment, rashes, infections, discomfort, and skin break down. 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$180,218 in federal fines across 4 penalties. 1 Medicare payment denial on record.
- $27,378 — penalty dated 2026-05-08
- $124,099 — penalty dated 2025-11-19
- $10,845 — penalty dated 2024-02-20
- $17,896 — penalty dated 2023-11-08
- Medicare payment denial — starting 2024-03-20 for 3 days
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 AVIR HEALTH GROUP — 116 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.3 | -1.3 vs chain |
| Health inspection | 1 of 5 | 2.4 | -1.4 vs chain |
| Staffing | 1 of 5 | 1.8 | -0.8 vs chain |
| Quality measures | 4 of 5 | 3.6 | +0.4 vs chain |
The other 115 homes this chain runs (chain average 2.3★, per CMS)
Showing 40 of 115; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| 2310 S ELDRIDGE PKWY HOLDINGS LLC | Organization | DIRECT OWNERSHIP INTEREST | since 08/24/2025 |
| GRAF HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 08/24/2025 |
| TX SNF HOLDINGS II LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 08/24/2025 |
| TX SNF HOLDINGS MEMBER, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 08/24/2025 |
| FREUND, NOCHUM | Individual | CORPORATE OFFICER | since 08/24/2025 |
| TRAVITSKY, AARON | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 08/24/2025 |
| DAGAN, AMITAI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 09/08/2025 |
| GOLDBERGER, ABRAHAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 09/08/2025 |
| GOLDBERGER, FAIGY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 09/08/2025 |
| 2310 S ELDRIDGE PKWY PROPERTY OWNER LLC | Organization | ADP OF THE SNF | since 08/24/2025 |
| WELLTOWER INC | Organization | ADP OF THE SNF | since 08/24/2025 |
| WELLTOWER NNN GROUP, LLC | Organization | ADP OF THE SNF | since 08/24/2025 |
| WELLTOWER OP, LLC | Organization | ADP OF THE SNF | since 08/24/2025 |
| GREEN, FREDDIE | Individual | ADP OF THE SNF | since 08/24/2025 |
| NGUYEN, CHARLES | Individual | ADP OF THE SNF | since 08/24/2025 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
8 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.
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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676066. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-08, 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.