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Bridgecrest Rehabilitation Suites

14100 Karissa Court, Houston, TX 77049 · For profit - Corporation · 130 certified beds · (713) 340-5200 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited May 20242 immediate-jeopardy citations$48,802 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $48,802 in federal fines (most recent 2024-05-03)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (1/5)

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

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

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

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5820 E Sam Houston Pkwy N · (713) 442-6000 · Call to confirm hours
Pharmacy
15411 Wallisville Rd · (281) 459-2740 · Call to confirm hours
Grocery
Food Town1.5 mi
5 Uvalde Rd · (713) 451-1355 · Call to confirm hours
Park
6500 E Sam Houston Pkwy N · (281) 452-1182 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.2%15.8%15.4%better
Long-stay residents who lose too much weight1.1%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.4%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.7%3.3%3.3%better
Long-stay residents whose ability to walk worsened10.4%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication21.0%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers1.6%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control1.8%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table7.6%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine99.2%88.0%79.4%better
Short-stay residents rehospitalized after admission22.5%25.7%22.6%typical
Short-stay residents with an outpatient ER visit11.7%12.3%12.0%typical

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.

48.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 58 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.6%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
69.2%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 69.2% 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 26 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 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 40% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.6%CMS range 36.2–59.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 6.9–17.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge69.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge65.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge61.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.7%CMS range 3.5–10.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.911.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.25
RN hours/ resident / day
0.95
LPN hours/ resident / day
2.12
Aide hours/ resident / day
3.32
Total nurse hours/ resident / day
0.24
RN hoursweekends
50.0%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 130 beds and averages 85.7 residents a day — about 66% occupied, or roughly 44 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.32 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 3.06 hrs/resident/day on weekends vs 3.42 on weekdays — 11% thinner on weekends. RN hours go from 0.25 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.

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

2
deficiencies at the latest standard inspection (2025-06-26)
4
at the previous standard inspection (2024-05-03)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

20 citations, most serious first. The 12 most serious are shown; the remaining 8 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-05-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (CR #1) of 6 residents reviewed for quality of care. The facility failed to ensure CR #1, who was cognitively impaired received adequate supervision when the facility sent her to the doctor's office unsupervised. CR #1 left the doctor's office and was found outside of the building next to a major freeway feeder road by the doctor's office manager. On 5/16/24 at 4:13 p.m. an immediate jeopardy (IJ) was identified. While the IJ was removed on 5/17/24 at 3:31 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure placed facility residents with dementia and impaired cognition at risk of neglect and elopement for lack of supervision during any appointment. Findings included:…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · K2023-11-14 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 allow adequate equipment for residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 36 Resident rooms (102, 104, 110, 111, 112, 113, 114, 115, 117, 118, 119, 123, 125, 201, 202, 203, 205, 206, 207, 208, 209, 210, 211, 213, 215, 217, 218, 219, 303, 309, 311, 313, 314, 315, 317 and 319) out of 37 resident rooms reviewed for environment. The facility failed to ensure all portions of the call system were functioning after loss of power by verifying that each resident room call lights were functioning effectively after repairs were made and verifying monthly thereafter. The facility failed to provide alternate means of communication with the staff that was always accessible to all residents while in their beds and in resident bathrooms to allow residents to call when needing staff assistance. An Immediate Jeopardy (IJ) was identified 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices for 1 of 4 hallways (Hallway 100) reviewed for supervision.The facility failed to ensure the exit door located at 100 hall was locked and secured on 04/15/2026. The failure resulted in the exit door located at the end of 100 hall observed to be unlocked/unsecured, allowing unrestricted resident access.Findings included:During an observation on 04/15/2026 at 2:38pm on the 100 hall, this surveyor observed CNA C using the key code to open the back exit door on the 100 hall to escort an unidentified resident from outside into the facility. This surveyor also observed CNA C exit through the same back door on the 100 hall without ensuring the door was re-secured or that the alarm system reactivated upon her departure, allowing the wind to repeatedly push the door open and closed.During an interview and observation on 04/15/2026 at 2:52pm with Resident #10, she stated that the exit door had been opening and closing while she was sitting nearby…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-04 · tag F0627 — isolated
    Ensure 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 that residents transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. The facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care and the reduction of factors leading to preventable readmissions for 1 of 1 resident (CR #1) reviewed for inappropriate discharges - The facility failed to develop a complete and accurate discharge summary/plan for CR #1's discharge on [DATE].- The facility failed to order necessary equipment (a hospital bed) for CR #1's discharge on [DATE].- The facility failed to provide CR #1's clinical information to the receiving personal care home when she was discharged on 01/23/26. These failures could place residents at risk of not having…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-26 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 care and services to prevent complications for 1 (Resident #58) of 2 resident reviewed for gastrostomy tubes (a surgically implanted tube into the stomach to provide delivery of nutrition). CNA-A paused the tube feeding pump, instead of informing the nurse immediately to turn off the pump for Resident #58, prior to lowering the head of bed (HOB). This failure could place residents with g-tubes at risk of complications such as aspiration, incorrect settings on the pump and delay in receiving feedings as physician ordered. Findings include: Record review of Resident #58's face sheet dated 06/25/25 revealed a [AGE] year-old first admitted to the facility on [DATE]. Diagnoses included multiple sclerosis (a chronic neurological disorder), muscle wasting, Dysphagia (swallowing disorder), Parkinsonism (a nervous system disorder), conversion disorder with seizures or convulsions (a mental health condition that causes physiological…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-10 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 residents (Resident #1) reviewed for pharmacy services. MA K attempted to administer Resident #23's Hydrochlorothiazide (used to treat high blood pressure and fluid retention) to Resident #1 instead of Hydralazine (used to lower blood pressure and improve blood flow) as ordered by the MD. This failure could place residents at risk of medication errors resulting in exacerbation or deterioration in health conditions. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnoses included hyperkalemia (high potassium), hypertension (high blood pressure), and pulmonary heart disease. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency for 1 of 1 incident reviewed for reporting. The facility failed to report to the State Survey Agency when Resident #1 was known to have been missing for approximately 1 hour after leaving the hospital where she went for a doctor's appointment. This failure could have affected residents by resulting in a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent harm, or impairment. Findings included: Record review of CR #1's face sheet dated 5/16/24 revealed a [AGE] year-old female admitted originally 7/9/20 and most recently 5/25/23. Her diagnoses were: Cerebral infarction (of stroke that occurs when a blood vessel in the brain is blocked, causing 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-03 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 a safe, clean, comfortable, and homelike environment for two of eighteen residents (Resident #27 and Resident #41) reviewed for safe, clean, homelike environment. -The facility failed to clean enteral feeding pumps and poles, which were dirty on 4/30/2024, 5/1/2024, and 5/2/2024 for Resident #27 and #41. -The facility failed to ensure the rooms were homelike and did not have peeling paint and well-maintained bedside tables on 4/30/2024, 5/1/2024, and 5/2/2024 for Resident #27 and Resident #41. This failure could affect the residents and place them at risk of an unsafe and an environment that was not homelike. Findings include: Resident #27 Record review of Resident #27's face sheet dated 5/2/2024 revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included dementia (group of symptoms that affects memory, thinking and interferes with daily life), contractures (permanent shortening of muscles,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-03 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for 4 (Resident #29, Resident #40, Resident #57, and Resident #41) out of 9 residents reviewed for care plan accuracy. -The facility failed to ensure Resident #29's most recent fall was care planned. -The facility failed to ensure Resident #40's hospice was care planned, along with her UTI/antibiotic. -The facility failed to ensure Resident #57's diet was updated on her care plan. -The facility failed to ensure Resident #41's PEG tube feeding was updated on her care plan. These failures could place residents at risk for their medical, physical, and psychosocial needs not being met. Findings include: Resident #29 Record review of Resident #29's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE], with an original admission date of 11/4/22. She had diagnoses of dementia (impaired ability to remember, think,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-03 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and record review, the facility failed to refer all residents with newly evident or possible serious mental disorders, intellectual disabilities, or a related conditions for level II resident review upon a significant change in status assessment for two of eighteen residents (Resident #1 and Resident #72) reviewed for PASARR evaluations. -The facility failed to refer Resident #1 to the appropriate, State-designated authority when she was diagnosed with MDD, intermittent explosive disorder, and psychotic disorder with delusions. -The facility failed to refer Resident #72 to the appropriate, State-designated authority when she was diagnosed with major depression and schizoaffective disorder. This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a possible decline in mental health. Findings include: Resident #1 Record review of Resident #1's face sheet dated 5/3/2024 revealed a [AGE] year-old woman admitted on [DATE]. The face sheet…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-03 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #64) of 9 residents viewed for infection control. -LVN D did not wear appropriate PPE when administering Resident #64's PEG (tube into stomach for nutrition) tube medications, when he was on Enhanced Barrier Precautions. This failure could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings include: Record review of Resident #64's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses of multiple sclerosis (immune system attacks covering of nerve cells in brain, optic nerve, and spinal cord), contusion (bruise) of right great toe, muscle wasting and atrophy, need for assistance with…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 4 of 12 residents (Residents #24, #25, #35 and #46) reviewed for respiratory care. 1. The facility failed to ensure Resident #24's nasal cannula tubing was dated and prefilled humidifier was dated. 2. The facility failed to ensure Resident #25's nasal cannula tubing was changed according to physician orders and the prefilled humidifier was dated. 3. The facility failed to ensure Resident #35's oxygen nasal cannula was changed according to physician orders. 4. The facility failed to ensure Resident #46's nebulizer face mask was bagged, labeled and tubing was changed according to physician orders. These deficient practices could place residents at risk of developing respiratory infections and complications. Findings include: 1.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 8 citations
  • Potential for harm · D2023-02-01 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure assessments accurately reflected the residents status for 1 of 16 residents (Resident #378) reviewed for accuracy of assessments. The facility failed to accurately assess Resident #378 for Central Venous Catheter dressing changes and capture dressing on the admission MDS. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings include: Record review of physician orders, dated January 2023, indicated Resident #378, admitted to the facility on [DATE]. Resident #378 was a [AGE] year-old male with diagnoses which included osteomyelitis (infection to the bone), diabetes mellitus (high blood glucose) with diabetic neuropathy (nerve damage to the lower extremities). The resident was ordered cefepime 1000 mg give 1 gm IV (intravenously) TID (three times every day). Record review of an order, dated 1/30/23, indicated the catheter dressing was to be changed, once…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-01 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 2 of 16 residents (Residents #76 and #378) reviewed for baseline care plans. 1. The facility failed to develop a baseline care plan or comprehensive care plan to address person-centered care for Resident #76. 2. The facility failed to develop a baseline care plan with interventions and goals for Resident #378's Central [NAME] Catheter (CVC) care. These failures could place residents at risk of not receiving care and services to meet their needs. Findings include: 1.Record review of a face sheet, dated 02/01/23 revealed Resident #76 was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included bacterial infection, hyperlipidemia (high fat in the blood) and edema (fluid retention-swelling). He was discharged…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-01 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and failed to ensure the comprehensive care plan described services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 16 residents (Resident #378) reviewed for care plans. The facility failed to ensure Resident #378's comprehensive person-centered care plan addressed the resident's risk, interventions or goals for dressing and care of a central line. This failure could place residents at risk of not receiving appropriate treatment and services. The findings were: Record review of physician orders, dated January 2023, indicated Resident #378, admitted to the facility on [DATE].…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident received care consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated it was unavoidable and residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #38) reviewed for pressure ulcers. The facility failed to ensure Resident #38 received wound care treatments to prevent the development of or worsening of pressure ulcers. This failure could place residents at risk for improper wound management, the development of new pressure ulcers and deterioration in existing pressure ulcers/injuries. The findings include: Record review of an undated face sheet for Resident #38 indicated a female who admitted to the facility on [DATE] and was [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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-01 · tag F0694 — isolated
    Provide 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 parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the residents' goals and preferences for one of one resident (Resident #378) reviewed for parenteral IV fluids. The facility failed to ensure the dressing covering for Resident #378's central venous (CVC) site to the right chest was changed after the resident admitted from the hospital on [DATE]. Resident #378's dressing was undated and had not been changed for 25 days and failed to apply an end cap, to prevent contamination to the intravenous tubing line when not in use. This failure could place residents at risk of the intravenous site becoming infected and the line becoming unusable. Findings include: During an observation and interview on 01/30/23 at 10:45 a.m., revealed Resident #378 was lying in bed. The resident had a central venous catheter (CVC [a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-01 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (nurse cart 200 hall) reviewed for labeling and storage. The facility failed to remove expired medication and expired glucose control solution from the nurse medication cart on hall 200. This deficient practice could place residents at risk for receiving outdated medications and improper glucose monitoring and could result in residents not receiving the intended therapeutic effects of their medications causing a health decline. Findings include: During observation of the medication cart on 200 hall on 01/31/23 at 9:50 AM revealed Resident #31 had Basaglar 100 units/milliliter insulin pen with an open date of 01/01/2023. The Label on the pen indicated to discard after 28 days of the open date. The glucose control solution on 200 hall medication cart was…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-01 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 4 hallways (hall 100) reviewed for environment and pests. The facility failed to ensure ants were kept out of the room of Resident #4. This failure could place residents at risk for ant bites and injury due to an ineffective pest control program at the facility. Findings include: Record review of Resident #4's face sheet, dated 01/30/2023, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included abscess of the buttock, muscle wasting, lack of coordination (difficulty maintain balance) and nausea. Record review of A Significant Change MDS Assessment for Resident #4, dated 9/12/2022, indicated she had moderate impairment in thinking with a BIMS score of 9. Resident #4 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. During an observation…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-06-26 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters in that: The facility failed to ensure the dumpster lids were closed on 2 of 2 dumpsters and the area surrounding the dumpsters were free of garbage and debris. These failures could affect residents who resided in the facility and the public by placing them at risk of exposure to germs, disease, and an environment which could attract pests and rodents. The findings include: In an observation on 6/24/25 at 9:35 AM of 2 of 2 dumpsters located outside the nursing facility, the lids were open on both dumpsters. The dumpsters were not full. Two disposable gloves, a mask, a bag of garbage, a tin can, and papers were on the ground next to the dumpsters. The Dietary Manager closed both dumpster lids immediately upon observation. During an interview on 6/24/25 at 9:37 AM, the Dietary Manager stated that the dumpster lids were to always remain closed to maintain pest control. She stated it had been the responsibility of all staff that use the dumpster to close the lid after…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$48,802 in federal fines across 2 penalties.

  • $8,827 — penalty dated 2024-05-03
  • $39,975 — penalty dated 2023-11-14

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

Part of a chain

This home belongs to FUNDAMENTAL HEALTHCARE — 66 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.4+0.6 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 1 of 52.2-1.2 vs chain
Quality measures 5 of 53.4+1.6 vs chain
The other 65 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Avir at MemorialDenison, TX 1 of 5Bennettsville Health And Rehabilitation CenterBennettsville, SC 1 of 5Calhoun Convalescent CenterSaint Matthews, SC 1 of 5Corinth Rehabilitation Suites on the ParkwayCorinth, TX 1 of 5Forest Haven Nursing And Rehabilitation CtrCatonsville, MD 1 of 5Julia Manor Nursing And Rehabilitation CenterHagerstown, MD 1 of 5Lake Emory Post Acute CareInman, SC 1 of 5Magnolia Manor - GreenwoodGreenwood, SC 1 of 5Magnolia Manor - InmanInman, SC 1 of 5Magnolia Manor - Rock HillRock Hill, SC 1 of 5Northampton Manor Nursing And Rehabilitation CenteFrederick, MD 1 of 5Oakbrook Health And Rehabilitation CenterSummerville, SC 1 of 5Oakland Nursing & Rehabilitation CenterOakland, MD 1 of 5Physical Rehabilitation And Wellness Center Of SpaSpartanburg, SC 1 of 5Riverside Health and RehabCharleston, SC 1 of 5San Gabriel Rehabilitation and Care CenterRound Rock, TX 1 of 5Springdale Healthcare CenterCamden, SC 2 of 5Berlin Nursing And Rehabilitation CenterBerlin, MD 2 of 5Bremond Nursing and Rehabilitation CenterBremond, TX 2 of 5Fairfield Nursing & Rehabilitation CenterCrownsville, MD 2 of 5Faith Healthcare CenterFlorence, SC 2 of 5Falcon Ridge RehabilitationHutto, TX 2 of 5Hillside Heights Rehabilitation SuitesAmarillo, TX 2 of 5Horizon Health And Rehabilitation CenterLas Vegas, NV 2 of 5Lancaster Health and RehabilitationLancaster, SC 2 of 5Las Ventanas De SocorroSocorro, TX 2 of 5Magnolia Manor - GreenvilleGreenville, SC 2 of 5Midlands Health & Rehabilitation CenterColumbia, SC 2 of 5Mira Vista CourtFort Worth, TX 2 of 5Moran Nursing And Rehabilitation CenterWesternport, MD 2 of 5North Las Vegas Care CenterNorth las Vegas, NV 2 of 5Pavilion at Glacier ValleySlinger, WI 2 of 5Sandy Lake Rehabilitation And Care CenterCoppell, TX 2 of 5Southpointe Healthcare and RehabilitationGreenville, SC 2 of 5Spanish Hills Wellness SuitesLas Vegas, NV 2 of 5Terra Bella Health and Wellness SuitesHouston, TX 2 of 5The Pavilion At CreekwoodMansfield, TX 2 of 5Villa Rosa Nursing And Rehabilitation, LLCMitchellville, MD 3 of 5Crimson Heights Health & WellnessHumble, TX 3 of 5Devlin Manor Nursing And Rehabilitation CenterCumberland, MD

Showing 40 of 65; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
LIBERTY COUNTY HOSPITAL DISTRICT NO 1Organization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/01/2017
STRATTON, CHARLESIndividualCORPORATE DIRECTORsince 03/31/2017
KARISSA HEALTH CARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2017
BAVARE, ARUSHAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
DUPREE, JEANNIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/21/2021
FORMAN, MURRAYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 11/26/2025
FUNDAMENTAL ADMINISTRATIVE SERVICES LLCOrganizationADP OF THE SNFsince 04/01/2017
FUNDAMENTAL CLINICAL AND OPERATIONAL SERVICES, LLCOrganizationADP OF THE SNFsince 04/01/2017

CMS files one row per role, so the 10 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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.

$7.9M
Net patient revenuemost recent cost report
-15.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 79%Medicare 4%Other / private 17%

About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$304per resident / day
operating cost
$9,248per month
≈ monthly operating cost
$264per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676362. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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