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Focused Care at Westwood

8702 Course Drive, Houston, TX 77099 · For profit - Partnership · 125 certified beds · (210) 705-4560 Medicare & Medicaid certified

Call the home — (210) 705-4560 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (1/5)

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

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

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

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

Location & what’s nearby

Hospital
Urgent care / clinic
9940 W Sam Houston Pkwy S, Suite 320
Pharmacy
9404 W Sam Houston Pkwy S · (832) 717-2811 · Call to confirm hours
Grocery
9460 W Sam Houston Pkwy S · (281) 299-6053 · Call to confirm hours
Park
(281) 568-1377 · Typically dawn to dusk
Place of worship
8800 W Sam Houston Pkwy S · (832) 769-7110

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 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 increased22.3%15.8%15.4%worse
Long-stay residents who lose too much weight1.9%3.0%5.4%better
Long-stay residents with a catheter left in their bladder1.5%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.6%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%2.4%6.5%check this — see note marked star 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 injury0.8%3.3%3.3%better
Long-stay residents whose ability to walk worsened10.2%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication7.8%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine98.9%98.0%95.3%typical
Long-stay residents with pressure ulcers4.8%3.8%4.7%typical
Long-stay residents with worsening bladder/bowel control11.6%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table4.9%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine94.2%88.0%79.4%better

* 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.

10.6%U.S. median 10.7%
Went back to hospital
0.39U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.11hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.39 therapist hours per resident per day in 2026Q1 — more than 66% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 6.7–17.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 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

0.22
RN hours/ resident / day
0.94
LPN hours/ resident / day
1.93
Aide hours/ resident / day
3.08
Total nurse hours/ resident / day
0.17
RN hoursweekends
38.9%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 125 beds and averages 98.7 residents a day — about 79% occupied, or roughly 26 beds typically open. It usually has some room. 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 3.08 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.22 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 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 2.69 hrs/resident/day on weekends vs 3.24 on weekdays — 17% thinner on weekends. RN hours go from 0.24 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

9
deficiencies at the latest standard inspection (2025-03-14)
4
at the previous standard inspection (2024-01-26)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · Gcited before2022-12-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 3 residents (Resident#33) reviewed for accidents. -The facility did not provide adequate supervision to prevent Resident # 33 from sustaining a burn to her right hand and right foot from a hot (noodle soup) spill. This failure could place residents at risk for serious injuries and pain. Findings included: Record review of the admission sheet (undated) for Resident # 33 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness (generalized), contracture, right hand and contracture of muscle, right hand. Record Review of Resident #33's comprehensive MDS assessment, dated 10/07/2022, revealed the BIMS score was 11 out of 15 indicating moderately impaired cognitive skills. Further review of the MDS…

    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 · E2026-06-16 · 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 residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 (Resident #1) residents reviewed for respiratory care.-The facility failed to ensure Resident #1 had an order for oxygen before administering oxygen at 3.5 L via nasal cannula from 05/12/26 through 06/16/26.This failure could have placed residents at risk of developing respiratory complications and a decreased quality of care.Findings included:Record review of Resident #1's face sheet dated 06/19/26 revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Resident #1 had diagnoses which included dementia (a loss of memory, language, and thinking abilities that were severe enough to interfere with daily life), COPD (lung disease that made it hard to breathe), and chronic…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 (Resident #1) reviewed for incontinent care. The facility failed to ensure Resident #1's supra pubic Foley catheter was placed below the bladder during wound care by LVN A and CNA A.These failures could place residents at risk for pain, infection, injury, and hospitalization.Findings include:Record review of Resident #1's face sheet reflected, the date of admission was 11/20/21 and was readmitted on [DATE]. Resident #1 had diagnoses which included history of recurrent, mild, neuromuscular dysfunction of bladder, (the nerves controlling your bladder are damaged and can no longer coordinate properly with the bladder muscles), constipation ( bowel movements that are infrequent, hard, dry or difficult to pass), bacterial infection, unspecified,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-06 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #1) reviewed for infection control. The facility failed to ensure LVN A used the required PPE for Resident #1, who was on enhanced barrier precautions while performing pressure ulcer treatment on 11/5/25. These failures could place residents at risk of cross-contamination and development of infection.Finding include:Record review of Resident #1's face sheet reflected, the date of admission was 11/20/21 and was readmitted on [DATE]. Resident #1 had diagnoses which included history of neuromuscular dysfunction of bladder, (the nerves controlling your bladder are damaged and can no longer coordinate properly with the bladder muscles), constipation (bowel movements that are infrequent, hard…

    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 · Fcited before2025-03-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. The facility failed to ensure staff did not store their personal items on the left second shelf of the walk-in cooler, including:. 1. Jumex mango energy drink can. 2. Red bull watermelon drink can 3. Coffee mate coconut liquid crème 32fl oz 4. A black and white with yellow brown flower lunch bag with 2 bottles of water, and one of the bottled water was open. The facility failed to ensure staff did not store three gray crates on the floor by Dishwasher A. These failures could place residents at risk for cross contamination and air-borne illnesses. Findings include: During an observation on 03/11/25 at 8:21 a.m., the following items were on the left second shelf of the walk-in cooler: a Jumex mango energy drink can, a Red Bull watermelon drink can, a Coffee-mate coconut liquid crème 32fl oz, and a black-and-white with yellow-brown…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-14 · tag F0813 — pattern
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    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 maintain and ensure safe and sanitary storage of residents' food items for 1 of 1 refrigerator reviewed for food safety. The refrigerator located on the 400 hall contained undated and unlabeled perishable food items. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations/Interview on 03/12/2025 at 02:12 p.m. revealed within refrigerator located on hall-400 behind locked code accessed glassed wooden door designated for resident's food brought from the outside contained: 1. Undated bag of plastic containers containing green vegetables and soup. 2. Unlabeled/undated bagged and boxed chicken and other unidentifiable food items. 3. Unlabeled/undated bagged containers of supplement shakes, and protein drinks. 4. Unlabeled/undated clear wrapped cup of sugar. 5. Unlabeled/undated bagged drink container not labeled or dated. 6. Unlabeled/undated bagged oranges not labeled or dated. Assistant Director of Nursing (ADON) A stated that the food in…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-14 · 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 resident rights, that include measurable objectives and time frames to meet a resident medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment that described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #49) reviewed for care plans. The facility failed to ensure Resident #49's Dementia and Hypertension diagnoses and medications were addressed in her comprehensive care plan. This failure could place residents at risk of not receiving appropriate care. The findings included: Record review of Resident #49's face sheet last captured 03/14/2025 reflected Resident #49 was a [AGE] year-old female originally admitted on [DATE] and readmitted [DATE]. Her medical diagnoses included Dementia…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-14 · 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 observations, interviews, and record reviews, the facility failed to ensure residents received care and treatment consistent with professional standards of practice to prevent pressure ulcers for one (Resident #49) of eight residents reviewed for pressure ulcers. 1. The facility failed to ensure Resident #49 was repositioned every two hours as indicated in Resident #49's physician orders on 3/11/2025 at 1:24 p.m. and 3/12/2025 at 11:49 a.m. 2. The facility failed to ensure Resident #49 was repositioned every frequently and as necessary as indicated in Resident #49's care plan. These failures could place residents at risk for worsening pressure ulcers, new pressure ulcers, or infection. Findings included: Record review of Resident #49's face sheet dated 03/12/2025 reflected Resident #49 was a [AGE] year-old female originally admitted on [DATE] and readmitted [DATE]. Her medical diagnoses included compression of brain (commonly occurring as a traumatic brain injury where the brain tissue is acutely or…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 for 1 of 3 residents (Resident #45) reviewed for incontinent care. The facility failed to ensure CNA O did not place the foley catheter bag on Resident #45's bed during wound care. This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings included: Record review of Resident #45's sheet dated 03/14/25 revealed a [AGE] year-old female was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #45 had diagnoses which included: hypertension (force of blood pushing against artery walls consistently too high pressure), respiratory failure (a serious condition that makes it difficult for a person to breathe without help) and pressure ulcer of right hip (injuries to the skin and the tissue below the skin that are due to pressure on the skin). 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-14 · 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 ensure based on a resident's comprehensive assessment, a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 3 (Residents # 32, #37 and #49) of 4 residents reviewed for g-tube medication administration . RN A failed to ensure Resident #32's GT (g-tube, a surgically placed device including a tube that leads from the outside of the body to the stomach to provide nutrition or medication) medications and water were administered by gravity, not by pushing the water via Resident #32's g-tube. RN A failed to ensure Resident #49's GT medications and water were administered by gravity, not by pushing the water via Resident #49's g-tube. LVN A did not check Resident #37's feeding bag for dates on 03/14/2025 during her shift. This…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-14 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices goals and preferences for 1 of 3 (Resident #49) residents reviewed for pain management. -CNA H failed to stop performing incontinent care while Resident #49 was in pain. -CNA H failed to notify the Wound Care Nurse of Resident #49's pain in a timely manner after incontinent care. These failures could place resident at risk for increased pain causing undue suffering. Findings included: Record review of Resident #49's face sheet, reflected she was a [AGE] year-old female originally admitted on [DATE] and readmitted [DATE]. Her medical diagnoses included compression of brain (brain tissue being acutely or chronically compressed commonly due to a traumatic brain injury), other speech and language deficits, cognitive communication deficit, Type 2…

    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 16 citations
  • Potential for harm · D2025-03-14 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that residents were free of significant medication errors for for 1 of 3 (Resident #49) residents reviewed for pharmacy services. The facility failed to ensure Resident #49 was free of significant medication errors when Resident #49 was reviewed for pain management in that: -CNA H failed to stop performing incontinent care while Resident #49 was in pain. -CNA H failed to notify the Wound Care Nurse of Resident #49's pain in a timely manner after incontinent care. These failures could place resident at risk for increased pain causing undue suffering. Findings included: Record review of Resident #49's face sheet, reflected she was a [AGE] year-old female originally admitted on [DATE] and readmitted [DATE]. Her medical diagnoses included compression of brain (brain tissue being acutely or chronically compressed commonly due to a traumatic brain injury), other speech and language deficits, cognitive communication deficit, Type 2 Diabetes Mellitus…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections including hand hygiene procedures to be followed by staff involved in direct resident contact for 1 (Resident #49) of 6 residents reviewed for infection control. -The facility failed to ensure CNA H utilized proper handwashing, infection control procedures , and completely cleaned Resident #49 when she did not open Resident #49's labia to clean or clean her buttocks and CNA H did not sanitize her hands between changing gloves during indwelling foley and incontinent care. - Wound Care Nurse failed to utilize handwashing, infection control procedure and completely clean Resident #49, during skin assessment, indwelling Foley and incontinent care when she did not open Resident #49's labia to clean and did not use…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-07 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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 observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 1of 6 residents (Resident #1) reviewed for cleanliness and sanitization. - The facility failed to ensure Resident #1 had a clean drinking cup. The noncompliance was identified as past noncompliance (PNC) and began on 02/20/2024 and ended on 02/20/2024. The facility corrected the noncompliance before the investigation began. These deficient practices could place residents at risk of living in an unsafe, unclean, and unsanitary environment which could lead to a decreased quality of life. The findings include: Review of Resident #1's Face Sheet, dated 02/20/2025, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] and expired on 02/17/2025. The resident's diagnosed included but were not limited to anemia (blood lacking healthy cells to carry oxygen…

    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 · Past Non-Compliance
  • Potential for harm · Dcited before2025-03-07 · 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 the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible, and each resident receives adequate supervision to prevent accidents for 5 (Resident #2, #3, #4, #5, #6) of 5 residents reviewed for accidents and supervision. -The facility failed to ensure that the facility's main door alarmed notifying staff when residents with wander guard's exited (Resident #2). -The facility failed to ensure the facility's main entrance wander guard alarmed when residents with wander guard's exited (Resident's #2, #3, #4,#5 and #6). This failure could place residents at risk of injury from accident and hazards. The noncompliance was identified as past noncompliance (PNC) and began on 08/02/2024 and ended on 08/03/2024. The facility corrected the noncompliance before the investigation began. The findings included: Resident #2 Review of Resident #2's Face Sheet, dated 02/20/2025, reflected the resident was a [AGE] year-old male…

    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 · Past Non-Compliance
  • Potential for harm · E2024-04-11 · tag F0644 — pattern
    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 interviews and record reviews a facility must coordinate assessments with the pre-admission screening and resident review (PASRR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes, Incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 5 of 5 (Resident #1, #2, #3, #4, #5.) resident with PASRR recommendations in that: Resident #1 NFSS for therapy services was not submitted timely. Resident #2 NFSS for therapy services was not submitted timely. Resident #3 NFSS for therapy services was not submitted timely. Resident #4 NFSS for therapy services was not submitted timely. Resident #5 NFSS for therapy services was not submitted timely. The Failures could affect residents who require PASRR services and could result in residents not receiving the PASSR recommended specialized services. The…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent decrease in range of motion for 1 of 12 residents (Resident #49) reviewed range of motion. -The facility failed to ensure Resident #49, with contractures to both hands, was wearing a hand splint device on both hands as care planned and ordered by the physician. - This failure could place resident at risk for further contractures of the hands and fingers, pain, and a decrease in quality of life. Findings: Record review of Resident #49's face sheet dated 11/01/2023 revealed a [AGE] year-old female admitted to the facility originally on 10/07/2020 and again on 05/09/2023 with the following diagnoses that included: subarachnoid hemorrhage (blood vessel that bursts in the brain) , sickle cell disorder with cerebral vascular involvement, cerebral infarction (disrupted blood flow to the brain), narcolepsy…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that The facility failed to prevent the following. 1. A Plastic Container of Shredded Cheese dated 1/15/24. 2. A Plastic Container of Mozzarella Cheese dated 1/02/24. 3. A Plastic Container of Chili dated 1/02/24. The scoop was left in the flour bin in the storeroom. These failures could affect residents who ate food from the kitchen and place them at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 01/23/24 at 8:30 AM revealed that leftover foods were not discarded prior to the use by date. Observation of the facility's food storeroom on 01/23/24 at 8:40 AM revealed that a scoop was left in the flour bin. Interview with the Food Service Manager on 01/23/24 at 8:45 AM he stated that the leftover food stored in the refrigerator should have been used or discarded prior to use by date. He stated that he will…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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 observation, interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 6 Residents (Resident #78) reviewed for administration. -The facility failed to completely and accurately document Resident #78's use of splint/braces on his care plan; These failures could place residents at risk of having incomplete and inaccurate records. Findings include: Record review of Resident #78's clinical record revealed he was a [AGE] year-old male who was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to include: cerebral palsy (disorder effecting movement and ability to maintain balance), depressive episodes, severe intellectual disabilities, pulmonary fibrosis (scarring of the lungs cause difficulty to breath), end stage renal disease (kidney failure), encounter for palliative care (medical care focused on pain relief and comfort), and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-26 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for Food and Nutrition Services in that -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings included: Observation on 01-23-24 at 9:10 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster ¾ full of garbage and food refuse and the door was wide open. In an interview on 01-23-23 at 9:20 am, with the Food Service Manager, he stated that the dumpster doors always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. He also stated that he will in service dietary staff that the dumpster door is to be always closed for proper sanitation and residents' safety. Requested a copy of policy and procedure for Waste Disposal/Dumpster of the facility. Facility did not provide the requested copy before exit.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-12-01 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 68 of 77 residents receiving meals other than via Gastrostomy tubes. -Opened packages in the walk-in freezer were not labelled or dated. -Food holding temperatures were not within safe parameters. -Food service staff were not able to state what safe reheating temperatures were. The deficient practice placed residents at risk for food-borne illness. Findings include: Observation on 11/29/2022 at 8:19 a.m. revealed the facility kitchen had a walk-in freezer. Observation inside the freezer revealed one blue plastic bag on a shelf. The bag was not labelled or dated. The contents were not visible. It was on top of an unopened box of Italian vegetable blend. Continued observation revealed a plastic bag that contained hashbrowns. The bag was not labelled or dated. Continued observation revealed a second plastic bag that contained a plastic tray half-filled with unknown contents. Observation on 11/29/2022…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-01 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out the activities of daily living received the necessary services to maintain grooming and personal hygiene care for two (Resident #49, and Resident #48) of four residents reviewed for ADL care. 1. The facility failed to ensure Resident # 49 was provided timely personal grooming (shaving). 2. The facility failed to ensure Resident #48 was provided showers as scheduled. These failures could place residents, who required ADL care, at risk of not receiving personal care and services and residents felt unkempt. Findings include: Record review of Resident #49's face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses were, dementia (impaired ability to remember things or make decisions that interferes with doing everyday activities), hypertension (persistently raised blood pressure), heart failure (heart does not pump enough blood 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide 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 received appropriate treatment and services to prevent urinary tract infections for 2 of 4 residents (Resident #21 and Resident #16) reviewed for catheter and incontinent care in that: 1. The facility failed to ensure LVN A followed proper infection control procedure during Resident #21's Foley care. 2. The facility failed to ensure WCN A placed Resident # 21's Foley bag below the bladder during turning and repositioning in bed. 3. The facility failed to ensure RCP AA utilized proper handwashing, infection control procedures, and completely cleaned Resident #16, during incontinent care. These failures could affect residents, who were incontinent or had a catheter, and place them at risk for urinary tract infections, discomfort, skin breakdown, and a decreased quality of life. Findings include: Record review of Resident #21's face sheet revealed a [AGE] year-old male was 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-01 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure 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 staff were able to demonstrate competency in skills and techniques 1 of 2 RCPs and 2 of 2 LVN (RCP AA G, LVN A and WCN A )observed for care, in that: 1. The facility failed to ensure LVN A followed proper infection control procedure during Resident #21's foley care. 2. The facility to ensure WCN A placed Resident # 21's foley bag below the bladder during turning and repositioning in bed. 3. The facility failed to ensure RCP AA followed proper hand hygiene technique, and separated the labia and buttocks during Resident # 16's incontinent care. These failure could affect residents who were incontinent and place them at risk for urinary tract infections, discomfort, skin breakdown, and a decreased quality of life. Findings include: Record review of Resident #21's face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were, neuromuscular dysfunction of bladder (lacks…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-01 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of two (Resident #181 and #33) of five residents reviewed for medication administration. -The facility failed to ensure Resident #181 and Resident #33 received medications as ordered by the physician. This failure could place residents at risk of medicinal adverse effects, decreased health status and being hospitalized . Findings include: Resident # 181 Record review of the admission sheet (undated) for Resident # 181 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included unspecified asthma, syncope and collapse and hypertension. Record review of Resident #181's baseline care plan, dated 11/23/22, read in part: .3. Health Conditions: 1a. oxygen therapy-while a resident. Record review of Resident#181's physician order, dated 11/25/22, revealed an…

    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 · E2022-12-01 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access for 2 of 5 residents (Resident #59 and Resident # 63) reviewed for medications in that: The facility failed to ensure Resident #59 and Resident# 63 did not have medication in their room. This failure could affect all residents and place them at risk for medication diversion, being administered the wrong medication, injury, and hospitalization. Findings include: Record review of the admission sheet (undated) for Resident #59 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included unspecified dementia, unspecified severity with other behavioral disturbance, obsessive-compulsive disorder, and cognitive communication deficit. Record review of Resident #59's quarterly MDS assessment, dated 10/25/2022, revealed a BIMS of 08 out of 15 indicating…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-01 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for 3 of 4 Residents(Resident #21, Resident #16 and Resident 10) reviewed for infection control. 1. The facility failed to ensure LVN A provided proper infection control procedures during foley care for Resident #21. 2. The facility failed to ensure WCN A provided proper hand washing and infection control procedure during wound care assessment and repositioning for Resident #21. 3. The facility failed to ensure RCP AA provided proper handwashing and infection control procedure during incontinent care for Resident #16. 4. The facility failed to ensure RCP AA provided proper use of PPE after providing a shower for Resident #10. These deficient practices could affect residents 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to FOCUSED POST ACUTE CARE PARTNERS — 25 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 51.9+1.1 vs chain
Health inspection 3 of 52.1+0.9 vs chain
Staffing 1 of 51.2-0.2 vs chain
Quality measures 5 of 54.0+1.0 vs chain
The other 24 homes this chain runs (chain average 1.9★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
FPACP HOUSTON LLCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 05/20/2019
CONLEY, SHAWNIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 03/07/2019
MCKENZIE, MARKIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 03/07/2019
STRUBBE, LORETTAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 03/07/2019
FOCUSED POST ACUTE CARE PARTNERS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/11/2025
FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/04/2025
BAILEY, KEISHAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/09/2024
CARSON, SABRINAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/23/2022
NGO, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/20/2019
ROBINSON-COBBIN, ROBBIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/04/2025

CMS files one row per role, so the 19 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$6.4M
Net patient revenuemost recent cost report
-6.0%
Operating marginrevenue minus expenses
$321K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 92%Medicare 2%Other / private 6%

About 92% 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. This home reported $321K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$220per resident / day
operating cost
$6,684per month
≈ monthly operating cost
$207per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676116. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-14, 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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