Jacinto Nursing and Rehabilitation Center
1405 Holland Ave, Houston, TX 77029 · For profit - Limited Liability company · 148 certified beds · (713) 455-1744 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, 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
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (36) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $59,867 in federal fines (most recent 2025-10-30)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.2% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.3% | 3.0% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.4% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.3% | 2.4% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.8% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 4.6% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 29.3% | 18.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.6% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 4.1% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.5% | 9.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.8% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 74.2% | 88.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 36.6% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.9% | 12.3% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.87 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.38 | 2.06 | 1.80 | better |
‡ 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.
Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not 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 SNF | 10.4%CMS range 5.1–18.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not 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 discharge | not 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 discharge | not 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | 0.73 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 148 beds and averages 72.7 residents a day — about 49% occupied, or roughly 75 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 3.09 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.12 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 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 2.74 hrs/resident/day on weekends vs 3.23 on weekdays — 15% thinner on weekends. RN hours go from 0.13 to 0.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
36 citations, most serious first. The 13 most serious are shown; the remaining 23 are one tap away and print in full.
- Immediate jeopardy · J2025-10-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure residents received adequate supervision for 1 of 5 residents (CR #1) reviewed for accidents. CR #1 eloped from the facility on 03/23/2025 while in the secured unit, through the window. CR #1 was found at a previous residence on 03/24/2025 and refused to return to the facility. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 03/23/2025 and ended on 03/24/2025. The facility corrected the non-compliance before the investigation, began on 10/14/2025. This failure could place the residents with exit seeking behaviors at risk for injury or death. Findings included:Record review of CR #1's previous facility note text, dated 01/01/2025 stated staff went to the resident's room and noted the window was open in the secured unit, resident was not found in the room. Staff immediately initiated their elopement protocol.Record review of CR #1's previous facility note text, dated 01/01/2025 stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2023-09-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers, promote healing, and to prevent new ulcers from developing for 1 (Resident #3) of 18 residents reviewed for pressure ulcers. - The facility failed to perform adequate skin assessments to identify pressure injuries for Resident #3, who was non-ambulatory and wheelchair bound. - The facility failed to identify and treat Resident #3's stage 2 (wound goes through skin and looks like a blister or ulcer but does not go through deep tissues ) and stage 3 (wound goes through deep tissue and fat but does not expose bone) pressure injuries. An Immediate Jeopardy (IJ) was identified on 9/4/2023. The IJ template was provided to the facility on 9/4/2023 at 1:00pm. While the IJ was removed on 9/7/2023 at 2:10pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of isolated due to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2023-09-07 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable, physical, mental, and psychosocial well-being of each resident for 1 (Resident #3) of 18 residents reviewed for Administration. - The Administrator failed to ensure nursing staff were performing weekly skin assessments on Resident #3 and other residents at the facility, causing Resident #3 to get facility acquired Stage 2 (wounds extends through skin and looks like a blister or ulcer but does not extend through deeper tissue) and Stage 3 (wound extends through deep tissue and fat but does not expose bone) pressure wounds. - The Administrator failed to ensure staff were performing showers and daily hygiene care on Resident #3 and other residents at the facility, causing Resident #3 to go a week without a shower which can cause skin breakdown. - The Administrator failed to ensure wounds were being identified and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-29 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by providing care including assessing, evaluating, planning and implementing resident care plans and responding to resident's needs for 1 (Resident #1) of 7 residents reviewed for nursing services. The facility failed to ensure that skin assessments were completed completely and correctly for Resident #1. This failure could place residents at risk of worsening skin conditions or infection. Findings included: Record review of Resident #1's face sheet dated 4/28/26, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including aphasia following cerebral infarction (inability to comprehend or communicate following a stroke) and anemia (deficiency…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-02-19 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 13 %, based on 4 errors out of 29 opportunities, which involved 2 of 7 residents (Resident #59, Resident #58) and one of five staff (MA V) observed during medication administration.1. MA V failed to administer Resident #59's Gabapentin 100 mg (used in treatment for neuropathy) and Pentoxifylline Extended Release 400 mg (used in treatment for peripheral vascular disease) according to physician orders, the medication was administered over one hour after the prescribed time. 2. MA V failed to administer Gabapentin 100 mg to Resident #59 from Resident #59's own supply of medications. MA V administered a Gabapentin capsule taken from a supply belonging to CR #10.3. MA V failed to administer Resident #48's Divalproex sodium Delayed Release 125 mg (used in treatment for bipolar disorder) according to physician orders, the medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-02-19 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 9 of 12 resident rooms and public areas reviewed for environment.1. The facility failed to ensure the floors were clean and not tacky, in the hallways where the following resident rooms were located: 202, 203, 204, 205, 206, 207, 222, 223 and 224.2. The facility failed to ensure the floor in the public restroom was clean and not tacky.These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Observation on 02/18/26 at 1:00 PM revealed the hallway floors were tacky where the occupied rooms numbered: 202, 203, 204, 205, 206, 207, 222, 223 and 224. The restroom used by staff and visitors had brown/black splatters on the walls and baseboards. The floor had black spots and was tacky when stepped on.In a telephone interview on 02/19/26 at 8:22 AM, the RP for CR #6 stated overall the facility was not clean, 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.
- Potential for harm · D2026-02-19 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 (Resident #1) of 6 residents (Resident #1) reviewed for foot care.The facility failed to obtain treatment orders and monitor the status of Resident #1's skin impairment to her toe. The facility failed to monitor and document the blood-tinged gauze present on Resident #1's toe on 2/17/26-2/18/26.This failure could result place residents at risk of in discomfort and/or infection.Findings include: Record review of Resident #1's admission record, dated 2/19/26, revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnoses included type 2 diabetes (a chronic condition that happens when you have constant high blood sugar), reduced mobility, mild cognitive impairment, pneumonia (an infection that inflames the air sacs in one or both lungs), and heart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-19 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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 a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 6 residents (Resident #12) reviewed for tube feeding.The facility failed to ensure Resident #12 received her enteral feeding, Jevity 1.5, at the rate assigned by the MD on 2/17/26 and 2/18/26.This failure could result in weight loss and dehydration.Findings include: Record review of Resident #12's admission record, dated 2/18/26, revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnoses included dementia, moderate protein-calorie malnutrition (occurs when there is a deficiency of protein and calories in the diet), anemia (a blood disorder that affects red blood cells and 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.
- Potential for harm · D2026-02-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of three medication carts (Medication Aide Cart 2-Front) reviewed for medication storage.1. The facility failed to keep residents' eye drop medications in their original containers/packaging. There was one box of Simbrinza 1%/0.2% (an eye drop used to treat glaucoma and high eye pressure) that had two resident name labels.2. The facility failed to label and identify the specific resident for whom the Artificial Tears-lubricant eye drops (designed for multiple administrations) were prescribed. These failures could place residents at risk of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-19 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen pantry and refrigerator located in the kitchen area that was reviewed for food procurement. The facility failed to ensure food items stored in the refrigerator were properly identified and dated when opened. The facility failed to train staff in identifying the importance of the sanitizing strips. The facility failed to discard expired food items found in the refrigerator. The facility failed to clean and sanitize the kitchen. The facility failed to repair a malfunctioning dishwasher temperature, resulting in inaccurate readings and the inability to verify proper sanitation of dishes. These failures could place residents at risk of foodborne illness, disease, and hospitalization.Findings include:Observation of the facility's kitchen and interview with the Dietary Supervisor on 02/17/26 between 8:45 AM and 9:30 AM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-22 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 housekeeping and the maintenance services necessary to maintain a clean, sanitary, safe, and comfortable environment for 7 of 10 resident rooms (Rooms #215, #216, #309, #311, #312, #313, and #314) reviewed for the environment. This failure could affect the health, safety and the dignity of the residents and other residents in the facility. Findings include: On 1/22/2026 at 9:05 a.m., an observation of resident room [ROOM NUMBER] was conducted. The bed was observed to be positioned close to a torn window blind. The floor of the room was observed to have thick, dark, dirty stains along the edges and corners. The walls were observed to be in poor condition with paint visibly peeling off in multiple areas. On 1/22/2026 at 9:08 a.m., an observation of resident room [ROOM NUMBER] was conducted. The floor of the room was observed to be dirty and sticky, dirty stains along the edges and corners. The walls were observed to be in poor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-22 · tag F0912 — isolatedProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet per resident for 2 of 6 multiple occupancy resident rooms (Rooms #311 and #314) reviewed for room size.Rooms #311 and #314 did not have the required 80 square feet per resident.These failures could place residents at risk of reduced living space and could affect their activities of daily living (ADLs).The findings were:Record review of Form 3740 Bed Classifications, signed by the Administrator on 1/15/26, revealed rooms #311, #312, #313, #314, #315, and #316 was classified to have 3 resident beds in each room.In an interview on 1/21/26 at 1:02 p.m., the Administrator said she did not have documentation to show that 3 beds were allowed in the room. She said the corporate office informed her in the past that they did not need a waiver. In an observation on 1/21/26 at 2:12 p.m., the Maintenance Director measured rooms #311 and #314 in the secure unit. Room size measurements were as follows:1. room [ROOM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-11-21 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 3 hallways, (Hall 200), conference room, and Resident #1 and #2's shared room. The facility had live flies in the room of Resident #1 and #2 located on Hall 200. The facility had live gnats in and outside the conference room located on Hall 200. This failure has the potential to place residents at risk for disease and a decline in their physical health. Findings included: Record review of Resident #1's Electronic Health Record revealed a [AGE] year-old male admitted to the facility on [DATE] with a principal diagnosis of Unspecified Psychosis not due to a substance or known psychological condition (when an individual exhibits psychotic symptoms such as hallucinations, delusions, or disorganized thinking, but the underlying cause is not attributable to substance use or a known physiological condition). Record review of Resident #1's Quarterly 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.
Show the remaining 23 citations
- Potential for harm · D2025-10-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Residents who are incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extend possible for 1 of 5 residents (Resident #1) reviewed for incontinent care. CNA A failed to place the urine collection bag of the indwelling urinary catheter below Resident #1's bladder after transferring from bed to chair.The failure could place residents with indwelling urinary catheters at risk for infection from potential backflow of urine into the bladder. Findings included:Record review of Resident #1's face sheet dated 10/16/25 revealed a [AGE] year old admitted to the facility on [DATE]. Resident #1's diagnoses included chronic kidney disease, and retention of urine.Record review of Resident #1's annual MDS dated [DATE] revealed a BIMS score of 10 out of 15 indicating moderate impaired cognition. Resident #1 was dependent on staff for most ADLs and had 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.
- Potential for harm · D2024-12-27 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse for 1 (Resident #1) of 7 residents reviewed for reporting abuse. -The facility failed to implement their written policy of abuse when facility staff failed to report to the Administrator when Resident #1 was found in bed tightening his call light wire around his neck and was sent to the hospital for a possible suicide attempt on 12/26/2024. -The facility failed to implement their written policy of abuse when the facility failed to notify the state agency of the allegation of abuse. This deficient practice could place residents at risk of continued and/or unrecognized abuse, neglect, exploitation, or mistreatment. Findings included: Record review of Resident #1's Face sheet dated 12/27/2024, he was a [AGE] year-old male originally admitted on [DATE] and most recently admitted on [DATE]. He was discharged from the facility on 12/26/2024. His medical diagnoses 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.
- Potential for harm · D2024-12-27 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 24 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to other officials including to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #1) of 7 residents reviewed for reporting. -The facility staff failed to report to the Administrator when Resident #1 was found in bed tightening his call light wire around his neck and was sent to the hospital for a possible suicide attempt on 12/26/2024. -The facility failed to report within the required time frame to the state agency when Resident #1 was found in bed tightening his call light wire around his neck and was sent to the hospital for a possible suicide attempt on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-12-05 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 3 of 90 days (9/21/24, 9/29/24, and 10/20/24) reviewed for RN coverage. The facility failed to ensure they had RN coverage for at least 8 consecutive hours on 9/21/24, 9/29/24, and 10/20/24. This failure could place residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: Record review of the staffing sign in sheets for 9/21/24, 9/29/24, and 10/20/24 revealed no RN signed in or on the schedule. Record review of the DON's electronic clock in sheet revealed she worked 4.6hrs on 9/21/24, she didn't work on 9/29/24, and worked 6.93hrs on 10/20/24. In an interview with the DON on 12/4/24 at 10:00am she said an RN must be at the facility for 8 consecutive hours a day. She said the RNs provided direct supervision, filled out incident reports, ran IVs and PICC (thin, flexible tube that's inserted into a vein in the arm and threaded into a large vein above the heart) lines, and ensured…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-05 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 17% based on 5 errors out of 29 opportunities which involved 2 of 9 residents (Resident #34 and #20) and 2 of 4 staff (MA A and LVN B) reviewed for medication administration. MA A crushed and administered Divalproex DR (a delayed release medication used to treat seizure disorders and mental/mood conditions) and Oxybutynin ER (an extended-release medication used to reduce bladder spasms and treats overactive bladder) to Resident #34 on 12/4/24. Delayed and Extended-release formulations should not be crushed. MA A administered Resident #48's Sertraline (used to treat depression) to Resident #34 on 12/4/24. MA A administered chewable Aspirin instead of enteric coated Aspirin to Resident #34 as ordered by the Physician on 12/4/24. LVN B administered Heparin lock flush (an anticoagulant that prevents blood clots in IV catheters) instead of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-05 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 2 of 8 residents (Resident #56 and Resident #20) reviewed for privacy in that: 1. LVN A failed to provide privacy while administering medications via g-tube (a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) to Resident #56 by not closing her privacy curtain on 12/04/2024. 2. LVN B failed to provide privacy while administering an IV flush to Resident #20 by administering his IV flush in the middle of the hallway on 12/04/2024. This failure could place residents at-risk of loss of dignity due to lack of privacy. The findings included: 1.Record review of Resident #56's face sheet dated 12/5/24 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnosis included gastrostomy infection (complication of gastrostomy tube placement), gastrostomy status (presence of an artificial opening to the stomach),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an infection 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 2 of 8 residents (Resident #20 and #56) reviewed for infection control. -LVN A did not wear appropriate PPE when administering medication via peg-tube care (PEG tubes allow you to receive nutrition through your stomach) to Resident #56 who was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) on 12/4/24. -LVN A de-clogged (remove or clear a blockage) Resident #56's g-tube using an oxygen key that was retrieved from her pocket on 12/4/24. -LVN B did not wear appropriate PPE when administering an IV picc line flush to Resident #20 on 12/4/24 who was on enhanced barrier precautions per facility protocol and care plan. These failures…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 maintained acceptable parameters of nutritional status, such as usual body weight for 1 of 5 residents (Residents #2) reviewed for nutrition. - The facility failed to follow up on the Registered Dietitian's recommendations for Resident #2's severe weight loss. This failure could place residents at risk for weight loss and decline in health status. Findings include: Record review of Resident #2's face sheet revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnoses included malignant neoplasm of head of pancreas (a type of cancer that begins as a growth of cells in the pancreas), moderate protein-calorie malnutrition, pain, type 2 diabetes, and heart failure. Record review of Resident #2's significant change in status MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15 which indicated severe cognitive impairment. She required partial to moderate assistance from staff with eating.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-15 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 6 residents (Resident #2) reviewed for pharmacy services. MA K administered Resident #4's Gabapentin (used to prevent and control seizures, and to relieve nerve pain) to Resident #2. This failure could place residents at risk of misappropriation of property and medication errors. Findings include: Record review of Resident #2's face sheet revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnoses included malignant neoplasm of head of pancreas (a type of cancer that begins as a growth of cells in the pancreas), pain, type 2 diabetes, and heart failure. Record review of Resident #2's significant change in status MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15 which indicated severe cognitive impairment. She required assistance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-07 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 ensure maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; environment for residents in the secured unit in rooms # 145, 215, 216, 310, 312,&room [ROOM NUMBER] room [ROOM NUMBER] had scraped wall by the sink and uneven floor on the entrance from 215 room [ROOM NUMBER]'s bathroom had an uneven floor. room [ROOM NUMBER], and 303 had a strong urine smell and bathroom floor was uneven. room [ROOM NUMBER] and 311 had an uneven floor. room [ROOM NUMBER]' bathroom floor bear covering off the floor. Hole behind the door. room [ROOM NUMBER]'s bathroom floor was partially covered half of the floor covering was off. Face board off the wall. room [ROOM NUMBER]'s had a dirty drinking cup. These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being. The findings included: Observation on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-07 · tag F0676 — failed to keep up residents' daily-living abilities — patternEnsure residents do not lose the ability to perform activities of daily living unless there is 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 provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for 1 of 3 residents (Resident #27) reviewed for activities of daily living. The facility failed to provide communication assistance to effectively communicate with staff for Resident #27. The facility failed to provide Resident #27 with showers according to shower schedule. These failures could place residents at risk of having decreased quality of life and loss of dignity. Findings included: Record review of Resident #27's face sheet, dated 09/01/2023, reflected a-[AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stroke (disrupted blood flow to the brain), expressive language disorder (inability to express thoughts by talking), high blood pressure, hemiplegia (paralysis)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-07 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 4 (Residents #27, #3, #23, and #64) out of 18 residents reviewed for ADL care. - Facility staff failed to provide scheduled showers to Resident #27, and Resident #3. - Facility staff failed to provide services to keep Resident #23 clean, shaved, and nails trimmed. - Facility staff failed to provide timely incontinent care to Resident #64. These failures could place residents who were unable to carry out ADLs, at risk of not receiving necessary personal hygiene, showers, and incontinent care, which could lead to skin breakdown, pain, and infection. Findings include: 1. Record review of Resident #27's undated face sheet revealed a [AGE] year-old male admitted on [DATE], with diagnoses of expressive language disorder (trouble using language), acquired absence of the right and left leg below the knee…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-07 · tag F0745 — failed to provide medically-related social services — patternProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 received medically related social services to attain or maintain the highest practicable physical well-being for 1 of 6 residents (Resident #27) whose records were reviewed for medically related social services, in that; Resident #27 was not assisted by a social worker with obtaining a viable means of communicating his thoughts, feelings, and preferences to staff. This deficient practice could result in loss of dignity and having unmet needs due to insufficient medically related social services. Findings included: Resident # 27 Record review of Resident #27's face sheet, dated 09/01/2023, reflected a-[AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stroke (disrupted blood flow to the brain), expressive language disorder (inability to express thoughts by talking), high blood pressure, hemiplegia (paralysis) affecting right (dominant) side, nicotine dependence (actively smokes), below 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.
- Potential for harm · E2023-09-07 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents reviewed for unnecessary medications. (Resident #64) The facility failed to have an appropriate diagnosis or adequate indication for the use of Resident #64's Seroquel (antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder). This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: Record review of Resident #64's face sheet dated 09/03/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY FACILITY Kitchen Based on observation, interview, and record review, the facility failed to store 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 discard expired/undated food items in the kitchen refrigerator. These failures could affect residents who ate food from the facility kitchen and place them at risk of foodborne illness. Findings include: Observation of the facility kitchen on 8/30/23 at 9:40 AM revealed food items that were expired and undated labeled ACTIVITIES: 2bottles expired OJ 7/21/2023 1 bottle sweet tea expired 6/14/2023 1 package of pre-cooked waffles labeled as received 6/2023 being kept in refrigerator rather than frozen per manufacturer's recommendation (manufacturer's recommendation was for item to be frozen) 1 package of [NAME] (unopened, date faded off) 1 package of lunch meat unopened, not labeled Interview on 8/30/23 at 8:40 AM, the DM said the activities department asked if they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-07 · tag F0914 — patternProvide bedrooms that don't allow residents to see each other when privacy is needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to designed or equipped resident's room in the secured unit (Room # 214, 215, 216, 304, 203, 304, 305, 306, 307, 308,309,310, 311, 312, 314 315) to have ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains to assure full visual privacy for each resident. All rooms in the secured unit had half visual cotton that provide partial privacy\covering to residents and responsible party that chooseice to visit. This failure could placed residents at risk of feeling insecure or uncomfortable in their rooms. Findings included: Observation on 08/30/23 from23 from 9:43 AM-11:00AM, revealed all rooms in the secured unit had half visual cotton that hunghang from the ceiling down. Observation revealed the following rooms had two residents each - Room # 302 was a two- person bedroom occupied by one resident. The visual cotton does not go around resident on B bed to provide full visual cotton bed Room # 303 was a two -person bedroom but had one resident A bed 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.
- Potential for harm · E2023-09-07 · tag F0919 — failed to provide a working call system — patternMake 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 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 9 (Resident bathrooms 214, 215, 217, and 218, and Resident rooms 229B, 308A, 308B, 313A, and 313B) out of 12 resident bathrooms and resident rooms reviewed for call lights. - The call light did not turn on when pushed for resident rooms 229B, 308A, 308B, 313A, and 313B. - The bathroom emergency light did not turn on when pulled for resident bathrooms 214, 215, 217, and 218. These failures could place residents at risk of falls and/or injuries if they are unable to get staff assistance when needed. The findings include: In an observation on 08/30/23 at 10:15am it was revealed the following rooms in the secured unit had call lights that did not function: - room [ROOM NUMBER], 215, 217, and 218 the bathroom emergency call light did not turn on when activated. - room [ROOM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-07 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment for 3 of 3 (Residents #27, #40, #15) residents reviewed for accuracy of assessment. -The facility failed to accommodate Residents #27's communication deficit by providing an alternative method to accurately complete his quarterly MDS assessment dated [DATE]. -The facility failed to accurately assess Resident #27 for his mental illness (qualifying diagnoses) on his quarterly MDS assessment dated [DATE]. -The facility failed to accurately identify Resident #40 with mental illness which had been identified on PASRR level II evaluation on her admitting MDS assessment dated [DATE]. - The facility failed to accurately complete Resident #15's admission MDS dated [DATE]; ethnicity/race was not identified, not assessed for BIMS score, assessed as having an ostomy bag on admission when they did not have one. These failures…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 2 of 18 residents (Residents #24, and #31) whose care plans were reviewed. - Resident #24 was not care planned for PTSD. - Resident #31 was not care planned for ROM and OT. These failures could place residents at risk of not receiving care and services needed to maintain their highest practicable quality of life. 1. Record review of Resident #24's undated face sheet revealed a [AGE] year-old female, readmitted on [DATE] with diagnoses of cerebral palsy (weakness or problems with using muscles), schizoaffective disorder bipolar type (hallucinations or delusions with mania and depression), conversion disorder with seizures (seizures with no neurologic cause), asthma (wheezing, breathlessness, chest tightness), PTSD (disorder caused…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-07 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 2 (Residents #31, and #21) out of 18 residents reviewed for care plan accuracy. - Resident #31 did not have her wound care added to the care plan. - Resident #21 did not have ROM, Restorative Carrot, or his Enteral Feed (provides nutrition through a tube into the stomach) added to the care plan. These failures could place residents at risk of not receiving care and services needed to maintain their highest practicable quality of life. Findings include: 1. Record review of Resident #31's, undated, face sheet revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses of paraplegia (paralysis of lower body), neuromuscular dysfunction of bladder (nerves and muscles in the bladder do not work), schizoaffective disorder, bipolar type (hallucinations or delusions with mania and depression), and muscle weakness. Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-07 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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 (Resident #4) with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 3 residents reviewed for limited range of motion. The facility failed to ensure that RCNA U provided passive range-of-motion appropriately and for prescribed amount of time for Resident #4. These failures could place residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings included: Record review of Resident #4's face sheet dated 8/31/23 revealed she was a [AGE] year-old woman initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included unspecified dementia/unspecified severity (group of symptoms that affects memory, thinking and interferes with daily life), aphasia (loss of ability to speak) following stroke (impaired blood flow to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-07 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 2 CNAs (CNA Z) serving and assisting residents in the dining area. - The facility failed to ensure dining room assistant (CNA Z) sanitized his hands between providing dining room assistance. This failure could place residents at risk for cross contamination. Findings include: Observation on 9/1/23 at 12:15pm revealed, CNA Z was feeding a resident during lunch. He walked away to go cut food for a second resident without sanitizing his hands. CNA Z then went to assist a third resident with opening a package. He then sanitized his hands at the closest sanitizing station which was located outside dining area before returning to the first resident that he was initially feeding. Interview on 9/1/23 at 12:17pm, CNA Z said that he was supposed to sanitize hands between residents to prevent cross contamination and admitted that he failed to do that because he was moving quickly and trying to help . Observed…
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.
- No harm found · C2023-09-07 · tag F0847 — widespreadInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to include in the facility's admission packets provided to residents and their representative on admission, inform regarding arbitration agreement if they chose to have one or not. The facility failed to ensure that current and potential residents were informed in a clear and understandable language about the facility's arbitration process. This failure could place the residents and their representatives at risk of being uninformed about their rights regarding binding arbitration and less able to defend their rights related to disputes, controversy or claims arising out of or related to the services provided by the nursing facility. The findings included: During the entrance conference on 08/30/23 at 9:30 AM with the ADM, a blank copy of the facility's admission packet and the binding Arbitration Agreement were requested. The facility administrator ADM provided a copy of the facility's admission packet. Record review of the facility's admission packet title admission agreement packet adopted 06-21 revised 05/24/23 no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$59,867 in federal fines across 3 penalties. 1 Medicare payment denial on record.
- $8,281 — penalty dated 2025-10-30
- $4,194 — penalty dated 2023-11-06
- $47,392 — penalty dated 2023-09-07
- Medicare payment denial — starting 2023-10-07 for 3 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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.
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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675231. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-19, 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.