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Falcon Ridge Rehabilitation

149 Klattenhoff Lane, Hutto, TX 78634 · For profit - Corporation · 140 certified beds · (512) 840-7000 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Dec 20231 immediate-jeopardy citation$8,577 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2023
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,577 in federal fines (most recent 2023-09-25)
  • 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4112 Links Ln Ste 201 · (512) 672-8933 · Call to confirm hours
Pharmacy
H-E-B0.7 mi
5000 Gattis School Rd · (512) 251-3173 · Call to confirm hours
Grocery
5000 Gattis School Rd · (737) 484-0700 · Call to confirm hours
Park
805 Estate Dr · (512) 759-4000 · Typically dawn to dusk
Place of worship
605 Winterfield Dr · (512) 271-5136

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.9%15.8%15.4%typical
Long-stay residents who lose too much weight3.9%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.3%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms3.1%2.4%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.9%3.3%3.3%worse
Long-stay residents whose ability to walk worsened12.7%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.6%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine92.6%98.0%95.3%typical
Long-stay residents with pressure ulcers2.1%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control6.3%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table11.5%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine78.8%88.0%79.4%typical
Short-stay residents rehospitalized after admission30.4%25.7%22.6%worse
Short-stay residents with an outpatient ER visit14.1%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.392.171.67better
Long-stay outpatient ER visits per 1,000 resident days1.742.061.80typical

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.

47.2% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.2%U.S. median 51.5%
Got home and stayed home
9.5%U.S. median 10.7%
Went back to hospital
60.9%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 60.9% 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 23 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF47.2%CMS range 34.8–61.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.5%CMS range 6.5–14.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge60.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge52.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge34.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting85.7%100.0%Oct 2024–Sep 2025CMS 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.4%CMS range 3.8–13.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.101.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.21
RN hours/ resident / day
0.86
LPN hours/ resident / day
1.91
Aide hours/ resident / day
2.99
Total nurse hours/ resident / day
0.19
RN hoursweekends
40.8%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 140 beds and averages 98.3 residents a day — about 70% occupied, or roughly 42 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.99 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.21 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 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 2.72 hrs/resident/day on weekends vs 3.10 on weekdays — 12% thinner on weekends. RN hours go from 0.22 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.

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

Inspection trend

3
deficiencies at the latest standard inspection (2025-03-20)
5
at the previous standard inspection (2024-01-25)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2023-11-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 the residents had the right to be free from abuse for one (Resident #2) out of three residents reviewed for abuse, in that: The facility failed to prevent a physical altercation between Resident #1 and Resident #2 that led to Resident #2 sustaining an abrasion to his left ear, redness to the back of the left side of his head and neck, causing him to have a headache and experience dizziness. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/31/23 at 3:00 PM. While the IJ was removed on 11/01/23 at 2:30 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk pain, injury, hospitalization, intimidation, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three resident reviewed for accidents. CNA A failed to get assistance while providing care for Resident #1 who was a 2 -person assist. CNA A and the MDS Nurse failed to lock Resident #1's bed and Geri chair (a specialized, highly padded recliner on wheels) while transferring Resident #1 via mechanical lift from the bed to the Geri chair. This failure could place residents at risk for falls, injury and hospitalization.Findings included:Review of Resident #1's face sheet, dated 06/16/2026, reflected a [AGE] year-old male, admitted [DATE] and readmitted on [DATE], with diagnoses that included Quadriplegia (the partial or total paralysis of all four limbs (both arms and both legs) and the torso), Unspecified intracranial injury with loss of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices during a mechanical lift transfer for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1 was transferred per mechanical lift by two people. CNA A transferred Resident #1 from his bed to his motorized wheelchair without the assistance of another person. This failure could place the residents at risk of not receiving the care and services to meet their needs and puts them at risk for injury. Findings included: Review of an undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included cerebral palsy (a neurological condition that affects movement and posture, caused by abnormal brain development or damage to the brain, often occurring before or during birth.), hemiplegia, affecting the right dominant side (Hemiplegia is a symptom that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-23 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care. The facility failed to give Resident #1 his Biofreeze Gel 4% scheduled medication during the standard time frame for 13 days and did not get his Biofreeze Gel at all on 06/19/2025. These failures placed residents at risk of pain, and a decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 06/23/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: pain in joint, muscle wasting, and type 2 diabetes mellitus with diabetic neuropathy (nerve damage due to diabetes). Record review of Resident #1's Quarterly MDS assessment, dated 04/29/2025, reflected the resident had a BIMS score of 15, which…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of six residents (Resident #36) reviewed for comprehensive care plans. The facility failed to ensure Resident #36's care plan addressed that the resident received hospice service. This deficient practice could result in a loss of quality of life due to residents receiving improper care. Findings include: Record review of Resident #36's face sheet, dated 3/19/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 had diagnoses which included COPD (a lung disease which makes breathing difficult), chronic congestive heart failure (the heart is not able to pump enough blood to meet the body's needs), anxiety,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-20 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food in the dry storage area was kept off the floor. This failure could affect residents by placing them at risk for accumulation of insects and/or rodents causing food-borne illness. Findings included: In an observation on 3-18-2025, at 8:45 AM, in the facility's dry food storage area, one loaf of bagged bread was observed to be on the floor. In an interview with the Dietary Manager on 3-20-2025 at 11:00 AM, it was revealed the Dietary Manager had worked at the facility for one month. The Dietary Manager said that it is all the kitchen staff's responsibility to ensure food in the dry storage area is kept off the floor to prevent cross contamination to the residents. The Dietary Manger stated his expectation was for food to be kept 6 inches off the floor and if food falls on the floor for it to be thrown away in the trash. In an 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-18 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to reside and receive services in the facility with reasonable accommodation of needs and preferences for 1 of 8 residents (Resident #1) reviewed for accommodation of needs. The facility failed to ensure Resident #1 could access his call button on 12/18/24. This failure placed residents at risk of not being able to call for help if they need it. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included history of traumatic brain injury, muscle wasting and atrophy (loss of muscle mass and tissue), cognitive communication deficit, and contracture of muscle in both upper arms. Review of the annual MDS assessment for Resident #1 dated 12/09/24 reflected a BIMS score of 14, indicating intact cognitions. It reflected he was completely dependent on staff for transfers from bed to chair. Review of the care plan for…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 8 residents reviewed for prevention of pressure ulcer. The facility failed to ensure Resident #2 received weekly skin assessments in accordance with his care plan. This failure placed residents at risk of pressure ulcers going untreated. Findings: Review of the undated face sheet for Resident #2 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included spastic quadriplegic cerebral palsy (a form of cerebral palsy that affects both arms and legs and often the torso and face), unspecified contracture of muscle, and muscle wasting and atrophy (loss of muscle mass and strength). Review of the admission MDS assessment for Resident #2 dated 10/07/24 reflected a BIMS score of 12, indicating moderately impaired cognition. It reflected he was frequently incontinent of bladder. There were no skin…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-15 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, personal and oral hygiene for two (Resident #7 and Resident #8) of three residents reviewed for ADLs. The facility failed to provide showers to Residents #7 and #8 in compliance with their shower schedules. This deficient practice could place residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth. Findings include: 1. Record review of Resident #7's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included unspecified dementia (impairment of brain functions), pain in shoulders, fractured sixth cervical vertebra, hyperkalemia (high potassium) and lack of coordination. Record review of Resident #7's admission MDS assessment, dated 09/30/24, reflected a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-10 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 of 1 activity programs and two (Resident #1 and Resident #2) of four residents reviewed for activities. 1. The facility failed to provide an activity program designed to meet the interests and needs of Residents #1 and #2. 2. The facility failed to notify all residents of canceled and postponed activity programs. This deficient practice placed all residents at risk for a diminished quality of life, isolation, lack of stimulation, and a decline in mental status. Findings included: Review of Resident #1's face…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-25 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a base line care plan that included the instructions needed to provide effective and person-centered care of the resident, for one Resident (Resident #2) of four residents reviewed for base line care plans. The facility failed to timely and accurately assess resident's care plan needs. 1. Resident #2's baseline care plan problem start dates and approach dates for Residents #2's were dated 22 days and 21 days, respectively, prior to her admission to the facility. 2. Resident #2's care plan failed to address her preferred language, incontinent care, delirium, cognitive loss/dementia, activity preferences, and communication needs. 3. The care plan failed to address that Resident #2's functional abilities and goals reflected the use of the mobility device walker, and not a wheelchair. These failures could affect all residents by placing them at risk for not receiving care and services to meet their needs. Findings included: Review of the undated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Dcited before2024-08-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. 1. The facility failed to ensure Resident #1's care plan, which called for floor mats to be on the floor at her bedside, was followed. No fall mat was observed beside Resident #1's bed. 2. The facility failed to prevent Resident #1 from sustaining a fall in her room and fracturing her left wrist. This deficient practice could affect residents by contributing to falls with injury, hospitalization, and death. The findings were: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, metabolic encephalopathy (a problem in 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-01-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen reviewed for sanitation. The facility failed to discard of food products that were past the use by date or in accordance with facility policy in the double door refrigerator, walk-in refrigerator, walk-in freezer, and dry storage area. The facility failed to label and date food products in the walk-in freezer and walk-in refrigerator. The facility failed to close food product bags in the walk-in freezer to prevent exposure to air. The facility failed to prevent mold growth on bottled products in the walk-in refrigerator. The facility failed to clean the industrial can opener. The facility failed to remove dented cans from the dry storage area to prevent service to residents. These failures could place residents at risk of cross contamination, loss of nutritional value, weight loss, and foodborne illness. Findings included: Observation on 01/23/2024 at 9:05 AM of the facility's only walk in freezer revealed an…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-25 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 (Resident #19, Resident #32, Resident #76) of 19 residents reviewed for ADL care. The facility failed to provide fingernail care for Resident #19, Resident #32, and Resident #76. This failure could lead to a reduction in quality of life and could contribute to health-related issues from lack of hygiene. Findings included: Review of Resident #19's Face Sheet dated 1/25/24, reflected a 65 year of age male, who was admitted to the facility on [DATE]. Resident #19 was diagnosed with Cerebral Palsy (group of disorders that affect a person's ability to move and maintain balance and posture), Hemiplegia-right dominant side (paralysis that affects only one side of the body), Congestive Heart Failure (serious condition in which the heart doesn't pump blood as efficiently as it should), 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-25 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1 (Hall 100-300) of 2 medication storage rooms and 1 (Rehabilitation Nurse's cart) of 3 medication carts reviewed for drug storage. The medication storage room for Halls 100-300 had one expired medication, one expired oral supplement and one expired topical paste used for ostomy (opening from inside the body to outside) care. The Rehabilitation Nurse's cart had one expired oral medication dated 2017. This failure placed residents at risk of receiving expired oral medications and supplements which could lead to reduced potency and adverse medication effects. Findings included: Observation and interview on 01/24/2024 at 7:32 AM in the medication storage room for 100-300 Halls revealed a bottle of Vitamin C 500 mg with an expiration date of 06/2021, a bottle of Clinical Nutrition Cranberry + Dietary Supplement expiration date 12/2023 and Ostomy care paste with an expiration date of 9/15/2023. Observation and interview on 01/24/2024 at…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-25 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of their quality of life for two (Resident #3, Resident #18) of six residents reviewed for rights. The facility failed to provide sufficient staffing in the dining area to ensure residents were assisted with their meals in a dignified one-to-one manner. CNA I sat between Resident #3 and Resident #18, who required assistance with their meals, and assisted both at the same time. These failures placed the residents at risk of a decline of their sense of dignity, level of satisfaction with life, and feelings of self-worth. Findings included: Review of Resident #3's undated Face Sheet, reflected a 52 year of age female, who was admitted to the facility on [DATE]. Resident #3 was diagnosed with Cerebral Palsy (group of disorders that affect a person's ability to move and maintain balance and posture), Quadriplegia (form of 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-25 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding for 1 (Resident #58) of 4 residents reviewed for enteral feeding. The facility failed to ensure that the head of Resident #58's bed was at an angle of at least 30 degrees and not more than 45 degrees while actively receiving enteral gastric tube feeding. This failure could affect residents in the facility receiving enteral feeding by placing them at risk of complications such as aspiration pneumonia. Findings Included: Review of Resident #58's Face Sheet dated 01/24/2024, reflected a 59 year of age male, who was admitted to the facility on [DATE]. Resident #58 was diagnosed with Parkinsonism (brain conditions that cause slowed movements, rigidity (stiffness) and tremors), Dementia (loss of cognitive functioning - thinking, remembering, and reasoning that interferes with a person's ADL), Acute…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 staff did not use physical, psychological, or verbal abuse on a resident for 1 of 5 residents (Resident #1) reviewed for abuse. Resident #1 stated CNA A had jerked him up out of bed at 2:00 AM to clean his room and CNA A told Resident #1 she didn't know why they were looking at his right leg because it needed to be cut off anyway. This failure could place residents at risk of fear and physical/psychosocial injury. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Surgical aftercare following trans-metatarsal amputation left lower extremity related to Diabetes Mellitus Type 2, Osteomyelitis (infection to the bone), peripheral artery disease , pressure ulcer of right heel stage 3, nicotine dependence, hypertension, anemia, anxiety, cognitive communication deficit, need for assistance with personal care, and adjustment disorder with…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-09 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for three (Resident #1, Resident #2, and Resident #3) of five residents reviewed for ADL care, in that: The facility failed to provide showers to Resident #1, Resident #2, and Resident #3 in compliance with their shower schedules. This deficient practice could place residents at risk of a decline in their sense of well-being, level of satisfaction with life, and at risk for skin breakdown. Findings included: review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including cerebral infarction , history of TIA (heart attack), history of falling, and muscle wasting and atrophy. review of Resident #1's quarterly MDS assessment, dated 09/29/23, reflected a BIMS of 6, indicating a severe cognitive deficit. Section G (Functional Status)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to store, prepare and ensure professional food service safety in the kitchen for all residents reviewed for sanitation, in that: Kitchen equipment was not clean/sanitary and there was standing water on the kitchen floor. This failure placed residents at risk for foodborne illness. Findings include: In an interview on 9/07/2023 at 2:10 PM with Dietary Manager revealed the kitchen did not have a mixer for making desserts, only a whisk. DM stated the deep fryer was dirty, and kitchen had not been using it because it needs a snake to clean it. DM further stated there were not enough food containers with proper fitting lids, and not enough large pots and pans. DM stated the facility cannot keep a dietary manager in the building. An observation on 9/07/2023 from 2:30 PM to 3:00 PM revealed the clean pots and pans had a brown substance on the exterior, and the baking sheets from the dishwasher were greasy to touch and had a blackish colored substance that transferred to the DM's finger on touch. Three steam wells had 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-15 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 one (Resident #1) of two residents reviewed for medication pass, in that: The facility failed to ensure Resident #1 was administered her medications within the one hour before and one hour after timeframe. These failures placed residents at risk for not receiving therapeutic effect of their medications as ordered by the physician. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, type II diabetes, heart failure, gout (painful arthritis), fibromyalgia (disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue and sleep disturbances), edema (swelling caused due to excess fluid accumulation in the body tissues),…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-08 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for two (Resident #1 and Resident #2) of four residents reviewed for rights, in that: The facility failed ensure Resident #1 and Resident #2 did not have to succumb to hearing and/or seeing their roommates engaging in sexual/romantic behaviors. This deficient practice placed residents at risk of a decline of their sense of dignity, level of satisfaction with life, and feelings of self-worth. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture),…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-08 · tag F0551 — isolated
    Give the resident's representative the ability to exercise the resident's rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to extend to the resident representative the right to make decisions on behalf of the resident for one (Resident #3) of four residents reviewed for resident rights, in that: The facility failed to inform Resident #3's Representative (RP) before administering him Lorazepam (a medication used to treat seizures or decrease anxiety). This failure could place residents at risk of receiving medication or treatment without consent. The findings included: Review of Resident #3's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive and irreversible condition that affects the brain), Parkinson's disease (a chronic disorder of the nervous system that affects movement and other functions), history of generalized anxiety disorder, muscle weakness, and age-related physical debility. Resident #1's RP was listed as his emergency contact, RP, and POA for financial and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-10 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide food that was palatable, attractive, and at an appetizing temperature for 71 out of 75 residents reviewed for nutritive value and appearance. The facility did not prepare and serve food that was palatable and attractive. The facility failed to ensure that food on the test tray did not have hair on it. These failures could place residents at risk for weight loss, altered nutritional status, cross-contamination, and diminished quality of life. Findings included: In an observation and interview on 11/08/2022 at 1:04 PM, Resident #58 had an uneaten pulled pork sandwich on his plate with pulled pork between two slices of white bread. The amount of pulled pork was not sufficient to cover the sliced bread. The area of the bread with the pulled pork was soggy and wet. Resident #58 stated he could not eat it because the bread was soggy. In an interview on 11/08/2022 at 10:22 AM Resident #64 said the food was not so great, and they used ground meat because it was cheaper. She said the food did not taste right…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-10 · tag F0806 — failed to honor food preferences — pattern
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 each resident received and the facility provided appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice for one (Resident #12) of five residents reviewed for substitution choices. 1. The facility failed to provide an acceptable substitute with similar nutritive value for residents served the chicken cordon bleu at lunch when the food supplier was out of chicken cordon bleu. 2. The facility failed to provide an alternate to the meal of similar nutritive value for Resident #12. These failures could place residents at risk for decreased oral intake, weight loss and decreased quality of life. Findings included: Review of Resident #12's face sheet dated 11/10/2022 revealed Resident #12 was a [AGE] year-old female on dialysis admitted to the facility on [DATE] with a diagnoses of End Stage Renal Disease (chronic disease in which the kidneys…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-11-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 under sanitary conditions in the kitchen and nutrition room [ROOM NUMBER] ice machine. -The facility failed to safely thaw ground beef for the evening meal. -The facility failed to clean the ice machine in nutrition room [ROOM NUMBER] as it was observed to have black mold and slime on the ice chute. -The facility failed to ensure hygienic practices in the kitchen when a hair was observed on the test tray food. These failures could place residents who received food from the kitchen and ice from the ice machine at risk of foodborne illness and decreased quality of life. Findings included: In an observation on 11/08/2022 at 9:45 AM in the kitchen, ground meat was in a sink wrapped in plastic in a sink with water. Water was not running over the ground beef. In an interview on 11/08/2022 at 9:50 AM, the DM stated he had just put the ground beef in the water to start thawing it about 10 minutes ago 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for one (Resident #28) of 23 residents reviewed for nutrition. The facility failed to ensure Resident #28 received the correct silverware that allowed Resident #28 to feed herself and subsequently lost weight as a result of inadequate oral intake. This failure could place residents at risk of not receiving appropriate calories and contribute to further weight loss. Findings included: Review of Resident #28's face sheet dated 11/10/2022 Resident #28 was revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of schizoaffective disorder, bipolar type (mental health disorder that is marked by a combination of schizophrenia and mood disorder), obesity,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for two (Resident #11 and Resident #46) of two residents reviewed for respiratory care. The facility failed to ensure the cleanliness of two resident's air filters on their oxygen concentrator machines. This failure could place residents at risk for equipment not working properly and decreased quality of life. Findings included: Review of Resident 11's face sheet on 11/10/2022 at 10:30 AM revealed diagnosis of Chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues), anxiety disorder, morbid (severe) obesity, urinary tract infections, major depression disorder, diabetes mellitus, and hypertension. Review of Resident 11's MDS revealed primary clinical category of pulmonary. Review of Resident 11's care dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-03-20 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose 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, it was revealed that 1 of 2 trash dumpsters, reviewed for proper trash containment, was not maintained in a sanitary condition to prevent the harborage of feeding pest. The facility failed to ensure an outside trash dumpster was properly sealed with the lid closed. This failure could place residents at risk of contracting disease by attracting pest and disease carrying rodents. Findings included: During an observation on 3-18-2025 at 9:00 AM, a large trash receptacle, containing trash, was in the back parking lot with the lid open. This trash dumpster was observed to not be in use. In an interview with the Dietary Manager on 8-18-2025 at 9:10 AM, it was conveyed the entire kitchen staff were responsible for keeping the lid closed on the trash dumpster when not in use. The Dietary Manager started that he expected staff to keep the lid closed on the dumpster as there was a risk of debris blowing outside the facility around residents. In an interview with the Dietician on 3-20-2025 at 11:34 AM, it was stated that her expectation 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.

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

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

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

Fines & penalties

$8,577 in federal fines across 1 penalty.

  • $8,577 — penalty dated 2023-09-25

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

Part of a chain

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

RatingThis homeChain avg
Overall 2 of 52.4-0.4 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 1 of 52.2-1.2 vs chain
Quality measures 4 of 53.4+0.6 vs chain
The other 65 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Avir at MemorialDenison, TX 1 of 5Bennettsville Health And Rehabilitation CenterBennettsville, SC 1 of 5Calhoun Convalescent CenterSaint Matthews, SC 1 of 5Corinth Rehabilitation Suites on the ParkwayCorinth, TX 1 of 5Forest Haven Nursing And Rehabilitation CtrCatonsville, MD 1 of 5Julia Manor Nursing And Rehabilitation CenterHagerstown, MD 1 of 5Lake Emory Post Acute CareInman, SC 1 of 5Magnolia Manor - GreenwoodGreenwood, SC 1 of 5Magnolia Manor - InmanInman, SC 1 of 5Magnolia Manor - Rock HillRock Hill, SC 1 of 5Northampton Manor Nursing And Rehabilitation CenteFrederick, MD 1 of 5Oakbrook Health And Rehabilitation CenterSummerville, SC 1 of 5Oakland Nursing & Rehabilitation CenterOakland, MD 1 of 5Physical Rehabilitation And Wellness Center Of SpaSpartanburg, SC 1 of 5Riverside Health and RehabCharleston, SC 1 of 5San Gabriel Rehabilitation and Care CenterRound Rock, TX 1 of 5Springdale Healthcare CenterCamden, SC 2 of 5Berlin Nursing And Rehabilitation CenterBerlin, MD 2 of 5Bremond Nursing and Rehabilitation CenterBremond, TX 2 of 5Fairfield Nursing & Rehabilitation CenterCrownsville, MD 2 of 5Faith Healthcare CenterFlorence, SC 2 of 5Hillside Heights Rehabilitation SuitesAmarillo, TX 2 of 5Horizon Health And Rehabilitation CenterLas Vegas, NV 2 of 5Lancaster Health and RehabilitationLancaster, SC 2 of 5Las Ventanas De SocorroSocorro, TX 2 of 5Magnolia Manor - GreenvilleGreenville, SC 2 of 5Midlands Health & Rehabilitation CenterColumbia, SC 2 of 5Mira Vista CourtFort Worth, TX 2 of 5Moran Nursing And Rehabilitation CenterWesternport, MD 2 of 5North Las Vegas Care CenterNorth las Vegas, NV 2 of 5Pavilion at Glacier ValleySlinger, WI 2 of 5Sandy Lake Rehabilitation And Care CenterCoppell, TX 2 of 5Southpointe Healthcare and RehabilitationGreenville, SC 2 of 5Spanish Hills Wellness SuitesLas Vegas, NV 2 of 5Terra Bella Health and Wellness SuitesHouston, TX 2 of 5The Pavilion At CreekwoodMansfield, TX 2 of 5Villa Rosa Nursing And Rehabilitation, LLCMitchellville, MD 3 of 5Bridgecrest Rehabilitation SuitesHouston, TX 3 of 5Crimson Heights Health & WellnessHumble, TX 3 of 5Devlin Manor Nursing And Rehabilitation CenterCumberland, MD

Showing 40 of 65; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
SOUTH LIMESTONE HOSPITAL DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 06/01/2019
PRICE, LARRYIndividualCORPORATE OFFICERsince 06/01/2019
RETAMA MANOR DEL RIO LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 06/01/2019
CALDERON, JORGEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/07/2024
FORMAN, MURRAYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 11/30/2025
FUNDAMENTAL ADMINISTRATIVE SERVICES LLCOrganizationADP OF THE SNFsince 06/01/2019
FUNDAMENTAL CLINICAL AND OPERATIONAL SERVICES, LLCOrganizationADP OF THE SNFsince 06/01/2019
KROL, MICHAELIndividualADP OF THE SNFsince 11/10/2022

CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$6.9M
Net patient revenuemost recent cost report
-21.5%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 69%Medicare 4%Other / private 27%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$289per resident / day
operating cost
$8,791per month
≈ monthly operating cost
$238per day
avg. revenue, all payers

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

What families pay in TX

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676382. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-20, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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