Solera at West Houston
2101 Greenhouse Road, Houston, TX 77084 · For profit - Limited Liability company · 112 certified beds · (281) 599-5540 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2024
- inspectors cited 1 immediate-jeopardy problem — 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 (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $87,386 in federal fines (most recent 2025-11-17)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 2 to 3 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 | 7.3% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.0% | 3.0% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 2.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.9% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.8% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.8% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.9% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 3.1% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.8% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.0% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.5% | 25.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.5% | 12.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.64 | 2.17 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.64 | 2.06 | 1.80 | 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.
53.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 280 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 102 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% 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 | 53.7%CMS range 48.3–59.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 8.6–14.2 | 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 | 63.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 69.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 33.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 93.3% | 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 | 95.8% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 90.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.7% | 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 | 7.5%CMS range 4.9–10.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 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 112 beds and averages 99.6 residents a day — about 89% occupied, or roughly 12 beds typically open. It runs fairly full. 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 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 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 2.96 hrs/resident/day on weekends vs 3.59 on weekdays — 18% thinner on weekends. RN hours go from 0.47 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
34 citations, most serious first. The 13 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · Kcited before2025-11-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents with pressure ulcers receive necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (CR #1) of 5 residents reviewed for wound care. The facility failed to properly identify the pressure ulcer and provide immediate oversight by a wound care specialist when the wound was first identified as a Stage 2 Pressure Ulcer on 10/15/25. CR#1 was admitted to the hospital on [DATE] with a necrotic pressure ulcer to the right heel and the need for possible amputation of the lower right extremity. On 11/17/25, CR#1's family member stated that CR#1's right leg was amputated above the knee due to an infected pressure ulcer of her heel. An Immediate Jeopardy (IJ) was identified on 11/14/25. The IJ template was provided to the facility on [DATE] at 3:31 pm. While the IJ was removed on 11/15/25, the facility remained out…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2024-12-30 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 (Resident #1) residents reviewed for abuse and neglect. The facility failed to ensure that Resident #1 was free from sexual abuse when staff observed Resident #1 being touched inappropriately by CR #2 on 12/26/2024. The noncompliance was identified as Past Non-Compliance. The IJ began on 12/26/2024 and ended on 12/27/2024. The facility corrected the noncompliance before the survey began. This failure placed residents at risk of experiencing abuse and neglect. Findings include: Record review of Resident #1's face sheet dated 12/27/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with anxiety disorder, unspecified, Malignant neoplasm of uterus (A cancerous tumor), Unspecified kidney failure (A condition where the kidneys are not functioning properly),…
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.
- Actual harm · Gcited before2024-03-22 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident's right to be free from abuse for 1 of 6 residents (Resident #1), in that:. CNA C was seen on camera being verbally abusive aggressive towards Resident #1 which resulted in the resident feeling unsafe at the facility. This failure could place residents receiving care at risk of experiencing continued psychological distress and declining mental health. Findings included: Record review of Resident #1's clinical notes dated 3/20/24 at 1:29am by the Social Worker, resident is alert and oriented x4 (a measure indicating an individual is aware of their surroundings, knows who they are, where they are and what time it is, a positive sign of cognitive function). Record review of Resident#1's facesheet dated 3/21/24 revealed he was admitted on [DATE] with diagnoses of transverse myelitis (spinal cord inflammation, causing pain, muscle weakness and paralysis), paraplegia (the loss of the ability to move the legs and lower body), ocular…
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 before2026-02-18 · 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 observation, interview, and record review the facility failed to ensure that resident with pressure ulcers receives treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1(Resident #1) of 5 resident's reviewed for pressure ulcers. -LVN A failed to follow physician orders while changing Resident #1's dressing to right hip. LVN A failed to apply skin prep to peri wound edge and apply Santyl (ointment used to remove dead tissue from skin ulcer) to resident wound bed. This failure could place residents with wounds at risk for delayed healing and tissue damage. Finding Included: Record review of Resident #1's face sheet dated 02/03/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 01/19/26. Resident #1's diagnoses included scoliosis (abnormal sideways curvature of the spine, forming an S or C shape), type 1 diabetes mellitus with hyperglycemia (blood sugar is above 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 · D2025-11-17 · 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 interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 (CR#1) of 3 residents reviewed for accuracy of assessments. The WCN failed to accurately document the presence of an existing wound on CR#1's weekly skin assessment after a new skin issue occurred on 10/15/25. CR#1's initial MDS Assessment failed to document the presence of a skin issue. These failures could place residents at risk for delayed treatment, worsening of condition, and hospitalization Findings include:Record review of CR #1's facesheet revealed a seventy-six-year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses was a pulmonary embolism without acute pulmonale (blood clot in the lung), secondary malignant neoplasm of bone (cancer that has spread throughout the body), hyperlipidemia, difficulty walking, and the presence of a pacemaker. Record review of CR#1's admitting hospital records dated 09/15/25 documented that CR#1 had Type 2 Diabetes, a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-25 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility must develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care and include the minimum healthcare information necessary to properly care for residents for 3 (Residents #139,#140, and #143) of 5 residents reviewed for baseline care plans -Resident #139 had a tracheostomy and an enteral feeding tube that were not baseline care planned. -Residents 139, #140, and #143's baseline care plans did not designate the code status of the residents. The failures could place the residents at risk for not receiving the care and services needed and placed them at risk for deteriorating health. Findings included: Resident #139 Record review of the admission Record for Resident #139 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-07-25 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #9 and #47) of 21 residents reviewed for comprehensive care plans. The facility failed to ensure that Resident #47 has a comprehensive care plan that included all care areas triggered on her assessment. The facility failed to ensure that Resident #9 comprehensive care plan included her hospice service and oxygen. These failures could place residents at risk of not receiving proper care and service to develop and improve their mental, physical and psychosocial well-being. Findings Included Resident#47 Record review of Resident#47 admission face sheet dated 7/25/2025 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included urinary tract…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-07-25 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel for three of five medication carts observed in common areas accessible to staff and residents. -Three unlocked and unattended medication carts were observed in areas accessible to residents, staff, and visitors. This failure could place residents at risk of ingesting medications not prescribed to them and placed the facility at risk for drug diversion. Findings included:Observation on 07/22/25 at 10:55 a.m. revealed an unlocked/unattended medication cart in front of room [ROOM NUMBER]. The cart was facing the door, which was closed. There was no staff visible from the cart. At 10:56 a.m. revealed MA A opened the door of room [ROOM NUMBER] and exited the room. MA A said the medication cart should have been locked. She said she thought she had locked it. MA A open the top drawer of the medication cart without using keys. Observation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-07-25 · 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
Based on observation, interview and record review, the facility failed to ensure that foods are store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen in that:1.Foods were not sealed, labeled, and dated.2.Plates with dried food particles were stored with clean plates.3. Food items on the steam table was not maintained at 135 degrees F and above.4. Equipment were clean.5. Dry storage room free of dented cans. These failures could place residents who ate food prepared by the kitchen at risk for food borne disease and illness. Findings included: Observation of the kitchen on 07/22/2025 at 9:10 AM revealed the following:1.The coffee machine had an accumulation of brown stains on the coffee machine. At the time the DM immediately started to clean the coffee machine.2.Plates and bowls with stains and food particles in them were stock with clean plates and bowls. Observation on 7/22/2025 at 9:30 am revealed the deep fat fryer had very dark oil and burnt food particles in it. Observation on 7/22/2025 at 9:35 am 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 · E2025-04-25 · tag F0583 — failed to protect personal privacy — patternKeep 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 3 of 4 residents (Resident #1 and Resident #2) reviewed for privacy in that: -The facility failed to ensure CNA B provided privacy during incontinent care for Resident #1. -The facility failed to ensure CNA C provided privacy during toilet use for Resident #2. -The facility failed to ensure CNA L provided privacy during incontinent care for Resident #3. These deficient practices could place residents at-risk of loss of dignity due to lack of privacy. Findings included: RESIDENT #1 Record review of Resident #1's face sheet dated 04/24/25 revealed a [AGE] year-old female was admitted to the on 03/26/25. Resident #1 diagnoses included: metabolic encephalopathy (a condition where brain function is disrupted), hypertension (force of blood against the walls of the arteries is consistently too high), and cognitive communication deficit (someone has difficulty communicating because…
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 · E2025-04-25 · 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 (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 2 of 3 residents (Resident #1and Resident #3) reviewed for ADLs. - The facility failed to ensure Resident #1 and Resident #3 were provided incontinent care in a timely manner by facility staff. These failures could place residents at risk for not receiving incontinent care needed to maintain personal hygiene which could lead to skin breakdown, pressure injuries or infection. Findings included: RESIDENT #1 Record review of Resident #1's face sheet dated 04/24/25 revealed a [AGE] year-old female was admitted to the on 03/26/25. Resident #1 diagnoses included: metabolic encephalopathy (a condition where brain function is disrupted), hypertension (force of blood against the walls of the arteries is consistently too high), and cognitive communication deficit (someone…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 residents (Resident #1 and Resident #3) reviewed for incontinent care. The facility failed to ensure CNA B properly cleaned Resident #1 during incontinent care when CNA B did not separate Resident #1's labia on 04/22/2025. The facility failed to ensure CNA L properly cleaned Resident #3 during incontinent care when CNA L did not separate Resident #3's labia during incontinent care on 04/24/2025. This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings included: 1. Record review of Resident #1's face sheet dated 04/24/25 revealed a [AGE] year-old female was admitted to the on 03/26/25. Resident #1 diagnosis included: metabolic encephalopathy (a condition where brain function is disrupted), hypertension (force…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-25 · 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
Based on observations, interviews, 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. 1. The facility failed to ensure foods were dated as opened/prepared discarded after used date of 2 - 3 days per facility policy. These failures could place residents at risk of food borne illness and disease. Findings Included: Observation of the 1 of 1 facility kitchen freezer on 04/22/2025 at 8:56 a.m., revealed the following: 1. 1-gallon ziplocked sealed bag full of frozen premade waffles unlabeled/undated. 2. 4-single waffles sealed in saran wrap unlabeled/undated. In an observation on 04/22/2025 at 08:56 a.m., during the initial tour with Dietary Manager (DM) of 1 of 1 walk-in freezers in 1 of 1 kitchen observed 1-gallon ziplocked sealed bag full of frozen premade waffles unlabeled/undated and 4-premade waffles sealed in saran wrap unlabeled/undated. In an interview on 04/22/2025 at 08:56 a.m., Dietary Manager (DM) stated the waffles were served…
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 21 citations
- Potential for harm · Ecited before2025-04-25 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 3 of 4 residents (Resident #1, Resident #2, and Resident #3) and 4 of 5 staff (CNA B, CNA C, CNA L, CNA F) observed for infection control. 1-The facility failed to ensure CNA B followed appropriate infection control and hand hygiene procedure during incontinent care for Resident #1 on 04/22/2025. 2-The facility failed to ensure CNA C followed appropriate infection control and hand hygiene procedure while assisting resident to the bathroom for Resident #2 on 04/22/2025. 3-The facility failed to ensure CNA L followed appropriate infection control and hand hygiene procedure during and after incontinent care for Resident #3 when she was seen leaving a resident's room with gloves on 04/24/2025. 4-The facility failed to ensure CNA F followed appropriate infection control when two plastic bags with soiled items were left opened and on 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 · Dcited before2025-04-25 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 7 residents (Resident #10 and Resident #22) reviewed. -The facility failed to ensure that Resident #10's status of full code was a focus area in the resident's comprehensive care plan and no intervention was in place. -The facility failed to ensure that Resident #10's status of allergies was a focus area in the resident's comprehensive care plan and no intervention was in place. -The facility failed to ensure that Resident #10's status of impaired thought processes was a focus area in the resident's comprehensive care plan and no intervention was in place. -The facility failed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #2) reviewed for accidents and for food trays left out in the halls after meals. -The facility failed to ensure CNA C used gait belt when she transferred Resident #2 from bed to walker and walked the resident to the bathroom. -There was a food cart with nine food trays eaten with cutlery left out in the hall observed on 4/23/2025 at 4:43am. This failure could place residents who required assistance from staff to transfer out of bed and ambulatory residents at risk for accidents and injury. The findings were: RESIDENT #2 Record review of Resident #2's face sheet dated 04/25/25 revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 diagnoses included: Parkinson's disease (a progressive neurodegenerative disorder leading to movement related to tremors, slow movement,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-25 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
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 dispose of garbage and refuse properly for 1 of 8 resident halls observed for proper garbage disposal. The facility failed to dispose of garbage when a food tray cart safely and properly with nine trays that were eaten including cutlery laying on the trays were seen outside the Kitchen entrance on 4/24/2025. This failure could place residents at risk of eating food incompatible with their prescribed diet and which could attract pests. Findings included: During an observation on 4/24/2025 at 4:43am, a food cart was observed in a resident hall directly in front of the kitchen door entrance with nine eaten food trays which were unsealed, with used cutlery on trays. Interview with LVN O on 4/24/2025 at 4:43am, they said the trays were from residents who preferred to have a later dinner. LLVN O said that a risk of leaving the trays out and not bringing them inside the Kitchen was that any resident could come and eat off the tray. LVN O said that it was also an infection control issue. Interview with 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 · Ecited before2024-09-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility staff failed to ensure residents with pressure ulcers received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of 5 residents reviewed for wound care. The facility failed to perform wound care for Resident #1 when her bandages became soiled with urine. The facility failed to request a PRN order to change the bandage on Resident #1's sacral wound if it became soiled. This failure could place residents at risk for infection, deterioration of the wound and diminished quality of care. Findings included: Record review of Resident #1 face sheet reviewed 9/18/24 revealed a forty-year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were an urinary tract infection, osteomyelitis of vertebra (form of spinal infection), pressure ulcer of the sacral region stage IV,…
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 before2024-09-18 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility staff failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #1) of five residents reviewed incontinent care. The facility failed to address the leakage of urine from Resident #1's urethra, causing her stage VI pressure ulcer to the sacrum to burn. This failure could place residents at risk for infection, deterioration of the wound and diminished quality of care. Findings included: Record review of Resident #1 face sheet reviewed 9/18/24 revealed a forty-year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were an urinary tract infection, osteomyelitis of vertebra (form of spinal infection), pressure ulcer of the sacral region stage IV, and quadriplegia (paralysis of all four limbs. Record review of Resident #1's baseline care plan completed on 9/9/24 documented that Resident #1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-20 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 6 residents (Resident #141) reviewed for medication administration were free of significant medication errors. Facility failed to administer medications according to physican ordeers: multivitamin with folic acid (medication used to treat or prevent vitamin deficiency due to poor diet, or certain illnesses for 6 Days (was not available in stock) to Resident #14. This failure could place residents at risk of harm, injury, illness or hospitalization. Findings included: Record review of the face sheet dated 06/19/24, for Resident #141 revealed that the resident was admitted to the facility on [DATE]. Resident #141's diagnoses included acute kidney failure with tubular necrosis ( small ducts in the kidneys that filter blood and remove waste and fluid are demaged) ; essential (primary) hypertension ( high blood pressure); occlusion and stenosis of unspecified carotid artery ( blockage and narrowing of neck artery); chronic viral…
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 before2024-06-20 · 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
Based on observation, record review and interview, 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. 1. The facility failed to ensure expired foods were not discarded 2. The facility failed to ensure food was labeled and dated. 3. The Ice Scoop was left inside the ice maker These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 06/18/24 at 8:17 AM revealed that the following foods were not discarded prior to the use by date . Highly perishable foods not dated should be discarded due to spoilage and bacterial growth if stored for longer time 1. Rice dated 06/11/24 no used by date 2. Plastic container of Sliced Cheese no label, no use by date. 3. Plastic container of sliced Bologna no label, no use by date. 4. Plastic container of deli ham dated 06/10 24, use by date 06/13/24. 5. Plastic container of Shredded cheese dated 06 /04/24 no use by…
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 before2024-06-20 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 three of three residents, (Resident #14, Resident #393 and Resident #397) and three of four staff (LVN C) reviewed for infection control and prevention, in that: 1. LVN C did not follow proper technique in cleaning the accu-check machine (monitor for checking blood sugar levels) between Resident #393 and Resident #397. 2. Resident #14's external urinary catheter tubing was found on the ground and touching the carpet floor. These failures placed residents at risk for the development and transmission of infectious diseases, urinary infections, respiratory infections, hospitalizations and death. Findings included: Record review of Resident #393's face sheet revealed a [AGE] year-old resident who was originally…
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 before2024-06-20 · 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 bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #48 ) of 5 residents reviewed for quality of care. 1. The facility failed to ensure Residents #48's urinary catheter leg strap was in place to secure the catheter. This failure could place residents with foley/urinary catheters at risk of catheter pulling causing pain and/or infection due to improper care practices and cross contamination. Findings include: Record review of Resident #48's admission record dated 06/17/2024, revealed a [AGE] year-old female admitted to the facility 05/28/2024. Record review of Resident #48's history and physical dated 05/28/2024, revealed a [AGE] year-old female with a past medical history of Chronic kidney disease, stage 3, edema (swelling), dyspnea (difficulty breathing), Other disorders of phosphorus metabolism,…
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 before2024-06-20 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 1 of 6 medication carts, and 1 of 2 medication rooms (Medication Room-Hall 500 to 800 and Medication cart 100, 500 and 600) reviewed for medication storage. - There was Azelastine Spray 0.1 % and Fluticasone Propionate 50 mg that were opened, and not dated found ?in the medication cart for Hall 100 - There was Humulin insulin that was opened and not dated in the medication room for halls 500-800 - 1 bottle of Daily Multivitamin formula + iron expired medication found in medication cart for Hall 500/600. - Evencare G2 glucose control solution, 3 bottles Drug buster, Even Care G2: 1. Low control solutions 2. High control solution, 2 Shiley ( Tracheostomy tube cuffed with inner cannula), 15 Intron safety IV…
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 before2024-06-20 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
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 dispose of garbage and refuse properly for dumpster A of 2 dumpster reviewed for Food and nutrition services. -The facility failed to ensure dumpster A lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings included: Observation on 06-18-24 at 8:45 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster A ¾ full of garbage and the door was open. In an interview on 06-18-24 at 8:45 am, with the Food Service Manager, he stated that the dumpster doors must always be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. He further stated that housekeeping, and nursing also discard their waste garbage in the dumpster. It is the responsibility of staff from dietary, nursing and housekeeping for ensuring the dumpster doors are kept closed. Dumpster doors are monitored by dietary, nursing and housekeeping as they put waste in the dumpster.…
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 · D2024-06-20 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 6 resident rooms (Resident #23): - Sugar Ants were on bedside table and nightstand in Resident #23's room and in a bathroom near the main entrance. These failures could place residents at risk for infections. The findings include: Record review of Resident #23's Face sheet dated 06/20/2024 revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: acute and chronic respiratory failure, with hypoxia or hypercapnia (difficulty breathing due to drop in oxygen intake), acute embolism and thrombosis of deep veins (restricted blood flow causing clots) of right upper and left lower extremities, acute kidney failure (decreased urine output causing swelling in lower extremities), unspecified, acute upper respiratory infection (infection of the nose and throat), adjustment disorder with anxiety, adjustment disorder…
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 before2024-06-06 · 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 that residents received appropriate treatment and services to prevent urinary tract infections for 1 of 6 residents (Resident #1) who were reviewed for incontinent care, in that: CNA A did not spread and clean Resident #1's labia and clean around the resident's bottom during incontinent care. These failures could affect residents who received incontinent care performed by facility staff and could result in urinary tract infections. Findings Included: Resident #1 Record review of Resident #1's admission face sheet revealed she was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction due to thrombosis (when blood clots blocks blood flow to the brain), hypertension (high blood pressure), chronic pain (pain that last for a long time), diabetes (high blood sugar), bacteria pneumonia (infection of the lungs cause by bacteria), seborrheic dermatitis( itchy scaley patches), rash (temporary break out red, bumpy 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.
- Potential for harm · Dcited before2024-06-06 · 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 establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #1) reviewed for infection control as evidence by: CNA A did not wash hands or use hand sanitizer after changing gloves and then applied antiseptic ointment to Resident #1's buttocks. These failures could affect residents who received incontinent care performed by facility staff and could result in urinary tract infections. Findings Included: Resident #1 Record review of Resident #1's admission face sheet revealed she was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction due to thrombosis (when blood clots blocks blood flow to the brain), hypertension (high blood pressure), chronic pain (pain that last for a long time), diabetes (high blood sugar), bacteria pneumonia (infection…
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 before2024-05-15 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure residents were free from mental and emotional abuse for 1 resident (Resident #1) reviewed for abuse. The facility failed to prevent CNA A from committing emotional and mental abuse by aggressively pulling Resident #1's blanket off of her and using profanity at LVN A outside of the resident's room. This failure placed resident at risk of possible emotional and mental anguish, abuse, and neglect. The noncompliance was identified as past noncompliance (PNC) and began on 04/08/2024 and ended on 04/08/2024. The facility corrected the noncompliance before the investigation began on 05/15/2024 at 11:24 a.m. Findings Included: Record review of Resident #1's face sheet dated 04/12/2024 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included cystitis (an infection of the bladder that almost always follows a bacterial infection in the urine), Guillain-Barre syndrome (immune system attacks the nerves…
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 before2024-03-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and record reviews, the facility failed to ensure that residents received adequate supervision to prevent accidents for 1 of 6 residents (Resident #1) whose care was reviewed in that: CNA F did not transfer Resident #1 using a mechanical lift with two-person assist. CNA F transferred Resident #1 alone. This failure could place residents who required supervision at risk for injury. Findings included: Record review of Resident#1's facesheet dated 3/21/24 revealed he was admitted on [DATE] with diagnoses of transverse myelitis (spinal cord inflammation, causing pain, muscle weakness and paralysis), paraplegia (the loss of the ability to move the legs and lower body), ocular hypertension (pressure increases within the eye and can cause damage and vision loss), anxiety disorder (group of mental illnesses that cause constant fear, worry and restlessness) and hyperlipidemia (abnormally high levels of lipids or fats in the blood). Record review of Resident #1's MDS dated [DATE] revealed that his…
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 · E2023-04-28 · 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 observations, interviews, and record reviews the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7%, based on 2 errors out of 26 opportunity which involved 2 (Resident #250 and Resident # 78) of 7 residents reviewed for medication errors. -RN A left substantial quantity of crushed medications in medication cup. After administered a Seroquel to resident # 78 thus doses of medication ordered were not administered. (Error # 1) -MA A did not administer Sucralfate oral suspension as ordered by the doctor. Zinc Sulfate 50mg., Zinc (220mg) tablet oral one time daily, Citalopram 20mg (tablet) 1 oral time daily were not administering according to physician's order to Resident #250. (Error # 2) These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings Included: Resident # 78 Record review of resident # 78's face sheet revealed a 40 -year-old…
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 before2023-04-28 · 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
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: Food items with an expired used by date. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease. Findings include: Observation of the facility's kitchen and interview on 04/25/23 between 8:15 am and 8:30 am with the Food Service Manager revealed the following: A plastic container of sliced Swiss Cheese with a used by date 03/10/23 in the walk-in refrigerator. A plastic container of sliced honey baked ham with a used by date 04/21/23 in the walk-in refrigerator A container of cooked carrots with a used by date 04/24/23 in the walk-in refrigerator A container of chili with a used by date 04/24/23 in the walk-in refrigerator Interview with the Dietary Food Service Manager on 04/25/23 at 8:35 AM, she stated that the container of food items with expired used by date should…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-28 · 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 drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles , included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts ( Medication Aide Cart for 700, and 800 hall) reviewed for medication storage. The facility failed to ensure the Medication Aide Cart for 700 and 800 halls did not contain opened medications that were not labeled with open date. The facility failed to ensure the Medication Aide Cart for 800 hall have medications stored in their original delivery packet. These failures could place residents at risk of not receiving the therapeutic benefit of medication or adverse reactions to medications. Findings Include: Observation on 04/26/23 at 3:44 PM, the Medication Aide Cart for 700 and 800 halls revealed the following. Medication revealed on 800 hall Medication Aide Cart had one bottle of artificial tear drop open and not dated. Medication revealed on 700 hall…
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 before2023-04-28 · 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 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. The facility failed to ensure RN A follow proper hand hygiene and infection control procedure while providing accucheck for Resident # 70. These deficient practices could affect residents and place them at risk for infection and reinfection. Finding included: Resident # 70's face sheet revealed a [AGE] year-old male admitted on [DATE]. He has diagnoses including atrial fibrillation (quivering or irregular heartbeat), urinary tract infraction, type 2 diabetes mellitus with hyperglycemia and ketoacidosis, essential (primary) hypertension (high blood or raised blood pressure) and hyperlipidemia (excess fats in the blood.). Record review of resident # 70's admission MDS assessment…
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
$87,386 in federal fines across 3 penalties.
- $69,735 — penalty dated 2025-11-17
- $8,827 — penalty dated 2024-12-30
- $8,824 — penalty dated 2024-03-22
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to CANTEX CONTINUING CARE — 37 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.1 | -0.1 vs chain |
| Health inspection | 2 of 5 | 2.9 | -0.9 vs chain |
| Staffing | 2 of 5 | 1.9 | +0.1 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 36 homes this chain runs (chain average 3.1★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SWEENY HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/01/2024 |
| PARK, KELLY | Individual | CORPORATE OFFICER | — | since 08/01/2019 |
| BRIGNAC, JESSE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2024 |
CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
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 676310. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-25, 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.