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Avir At Jacksboro

211 E Jasper St, Jacksboro, TX 76458 · For profit - Corporation · 104 certified beds · (940) 567-2686 Medicare & Medicaid certified

Call the home — (940) 567-2686 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation$23,813 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $23,813 in federal fines (most recent 2023-08-26)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (57%) runs well above the national median (45%)

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 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 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
217 W Belknap St · (940) 567-8114 · Call to confirm hours
Pharmacy
104 E Belknap St · (940) 567-5576 · Call to confirm hours
Grocery
523 N Main St
Park
Fort Richardson Texas State Park · (940) 567-3506 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.8%15.8%15.4%better
Long-stay residents who lose too much weight0.0%3.0%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%2.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.7%3.3%3.3%better
Long-stay residents whose ability to walk worsened4.9%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication9.8%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine93.5%98.0%95.3%typical
Long-stay residents with pressure ulcers0.7%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control1.5%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table4.2%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication3.3%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine96.7%88.0%79.4%better
Long-stay hospitalizations per 1,000 resident days1.262.171.67better
Long-stay outpatient ER visits per 1,000 resident days1.412.061.80better

* 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.

13.2%U.S. median 10.7%
Went back to hospital
70.8%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.10hours / resident / day
Speech therapy

Met the expected recovery: 70.8% 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 24 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 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.2%CMS range 7.7–19.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge70.8%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 discharge62.5%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 discharge70.8%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 identified92.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.9%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.361.02Oct 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
1.09
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.53
Total nurse hours/ resident / day
0.16
RN hoursweekends
57.1%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 104 beds and averages 53.1 residents a day — about 51% occupied, or roughly 51 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.21 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.21 hrs/resident/day on weekends vs 3.66 on weekdays — 12% thinner on weekends. RN hours go from 0.24 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above 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 (2026-01-15)
6
at the previous standard inspection (2024-10-04)

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.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · H2023-08-26 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    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, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one of one resident (Resident #40) reviewed for quality of care . The facility failed to ensure Resident #40 had physician orders regarding care of the surgery site, post hip replacement surgery, on 07/30/2023. The 8 surgical staples were not removed until 08/13/2023, 14 days after surgery which resulted in a superficial infection. This failure could place residents at risk of unmet care needs and infection. The findings include: Record review of Resident #40's Face Sheet, not dated, revealed a [AGE] year-old male who was admitted to the facility on [DATE] for aftercare following right hip replacement surgery on 07/20/2023. Resident #40 had diagnoses which included dementia (a decline in cognitive abilities that impacts 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 · E2026-06-01 · 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 that the residents were treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 of 7 residents (Resident #2, Resident #3, Resident #4) reviewed for resident rights. The facility failed to ensure Resident #2, Resident #3, and Resident #4 were able to exercise his or her rights as a resident of the facility and as a citizen of the United States to be treated with dignity. The facility failed to ensure Resident #2, Resident #3, and Resident #4 exercised his or her rights without interference, coercion, discrimination, or reprisal from the facility staff. The facility failed to support Resident #3 in exercising her rights to have her personal property as required. This failure could place the residents at risk of inadequate care and services and/or unmet mental health needs.Findings included: Record…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-01 · tag F0656 — failed to write and follow a full care plan — pattern
    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 interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 7 residents (Resident #3, Resident #4, Resident #5) reviewed for care plans.The facility failed to ensure the staff developed the comprehensive care plan goals and interventions from the comprehensive assessment for Resident #3, Resident #4 and Resident #5. The facility failed to ensure the comprehensive care plans for Resident #3, Resident #4 and Resident #5 described the resident's goals for admission and desired outcomes. The facility failed to ensure the comprehensive care plan for Resident #3, Resident #4 and Resident #5 described the resident's preference and potential for future discharge. The facility failed to ensure the comprehensive care plan Resident #3, Resident #4 and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-01 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 1 kitchen as evidence by: The facility failed to ensure:Cook A wore a hair restraint properly covering his facial hair. These failures could place residents at risk for foodborne illness and compromised health status and hair in food.The findings included:In an observation of food preparation on 03/31/26 at 11:45 am, [NAME] A did not have a hair restraint covering his facial hair. In a follow-up observation and interview during food preparation on 04/01/26 at 12:25 pm, [NAME] A did not have a hair restraint covering his facial hair. In an interview, [NAME] A said that he should wear a hair restraint to cover his facial hair but forgot to put one on. He said a potential negative outcome would be that residents would have hair in their food. The Dietary Manager was not available for interview. In an interview on 04/01/26 at 1:40 pm, the Administrator said it was her expectation that staff wear…

    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 · Fcited before2026-01-15 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 1 of 12 months (July 2025) reviewed for RN Coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for 6 of 31 days in July of 2025. This failure placed all residents at risk for inconsistency in care, services and decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.Findings include: In a record review and interview on 01/15/2026 at 05:45 PM, with the Administrator regarding RN week-end coverage, she stated she knew there were days or weekends that were not covered as required. The Administrator provided the staffing schedule and time sheets. Record review of Daily Staffing Hours vs. Daily Staffing Sign-in Sheets, regarding RN coverage presented by the Administrator revealed the following days did not have RN coverage for at least eight consecutive hours a day, seven days 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-15 · 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 prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure proper sanitization of kitchen waste was kept in tightly closed trash cans.2. The facility failed to ensure that personnel change their gloves and wash their hands before serving and in between tasks. 3. The facility failed to ensure that food and nutrition services staff wear hair restraints. These failures placed the residents at risk of foodborne illness and being served food items that may be contaminated.The findings included: Observation on 01/13/2026 at 9:30 AM revealed the DM entered the kitchen and did not immediately wash her hands. She did not handle any food or food service equipment. During an observation and interview on 01/13/2026 at 9:39 AM, [NAME] O was not wearing a facial hair restraint or mask to cover his beard. [NAME] O reported he sometimes wore a facial hair mask and reported that his facial hair…

    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 before2026-01-15 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 16 of 52 rooms (Room #s 3, 4, 6, 10, 12, 14, 22, 43, 44, 46, 47, 50, 51, 52, 53, and 54) observed for cleanliness and condition. 1. The doorway transition strips used to provide a smooth floor transition between the hallway and the room for the door thresholds were missing for resident Room #s 10, 12, 43, 44, 46, 47, 51, 52, and 54.2. Square vinyl floor tiles were broken and/or missing in Room #s 14, 22, 43, 44, 50, and by the nurse's desk in Hall C.3. The floors were soiled with a dark-colored build-up of dirt along the base of the toilets, cove-base (vinyl baseboard), and door frames in the restrooms for Room #s 3, 4, and 6.4. A fly paper glue strip was hanging on the wall above the head of Bed A in room [ROOM NUMBER].5. The floor in room [ROOM NUMBER] was soiled with chewing tobacco, and an open dresser drawer had a pizza box…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-11 · 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 a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 1 resident (Resident #1) reviewed for respiratory care. 1. The facility failed to ensure Resident #1's nebulizer nasal cannula and oxygen nasal cannula was kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. The findings included: Record review of Resident #1's face sheet, dated 12/10/2024, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (severe or complete loss of strength or paralysis), Shortness of breath, Nasal congestion (stuffy nose), nutritional deficiencies, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-04 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (April 2024, May 2024, and June 2024) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 19 days of 91 days in April, May, and June 2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Record review of the CMS' PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 3, 2024 (April 1, 2024 - June 30, 2024), run date 09/24/2024, revealed partial (on 04/27/24) or no evidence of RN coverage for 19 of 91 days: 1. 04/06/2024 with no RN coverage. 2. 04/07/2024 with no RN coverage. 3. 04/13/2024 with no…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-04 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: A. The facility's walk-in refrigerator had dust, food crumbs, and dried, spilled milk on the floor and underneath shelves. B. Kitchen floors were not swept and free from dirt, food particles, and trash. The facility's failure could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status. The findings included: Observation on 10/02/24 beginning at 9:40 AM, during the initial tour of kitchen, revealed refrigerator #1 had spilled, dry milk on the bottom in multiple areas, and underneath the shelves. In the corners and against the wall, there was dust and food crumbs. In the kitchen area, the floor was dirty with dirt and food crumbs and trash underneath the shelves and along the walls. In a follow-up interview and observation of the kitchen on 10/02/24 at 11:00 AM, there was no change in the soiled floors. In refrigerator…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-04 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #28) of 5 residents reviewed for infection control, in that: The facility failed to ensure clinical staff donned (put on) proper personal protective equipment when providing care to Resident #28, who was on contact isolation precautions, including gown, gloves, and mask. Facility failed to ensure that staff used proper laundry handling precautions. This failure could affect residents and place them at risk for cross contamination and infections. The findings included: Record review of Resident #28's face sheet dated 10/04/2024 revealed a [AGE] year-old male admitted to facility originally on 01/04/2024 with readmission on [DATE]. His diagnoses included: Non-ST elevation myocardial infarction (heart attack),…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · Ecited before2024-10-04 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 1 facility reviewed for environmental concerns. The facility failed to replace a ceiling panel, repair water discoloration marks, repair the leak in the ceiling in Resident #29's room and repair water discoloration marks and the sagging ceiling in the dining area. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: Observation on 10/02/2024 at 05:35 PM revealed the following: 1. The ceiling inside Resident #29's room near the door was the area of concern. An approximately 2 feet by 2-foot square area of watermarked discolored sheet rock was noted in the ceiling. The area appeared to be a previous replacement or repair. Edges of the area appeared to be worn away due to moisture. A black substance was noted on the middle of the sheet rock patch, and in three other areas on patches. Water…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-04 · 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 a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 resident (Resident #11) reviewed for respiratory care. 1. The facility failed to ensure Resident #11's nasal cannula was kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. The findings included: Record review of Resident #11's face sheet, dated 10/04/2024, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #11 had diagnoses which included Dependence on Supplemental Oxygen (requires supplemental oxygen to properly breathe), Chronic Respiratory Failure with Hypoxia (occurs when the body has low levels of oxygen in the body causing breathing difficulty), Unspecified Chronic Bronchitis (inflammation of lungs…

    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 · D2024-10-04 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured in locked compartments and permit only authorized personnel to have access to the keys for 1 of 2 medication carts observed for medication storage. The facility did not ensure the Medication Cart (C/D hall cart) was locked and secured. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them. Findings included: Observation on 10/04/2024 at 11:57 AM revealed the medication cart for C/D hall was found unlocked parked on the left side of the nurse's station. There was no nurse in sight, and no nurse near the nurse's station. The medication cart was unattended. Medications in the cart included prescription medications, over the counter medications and narcotics. In an interview on 10/04/2024 at 12:36 PM RN B stated she was not aware that the medication cart was unlocked. She further stated that the medication cart is to be locked at all times when not in use by the nurse. She continued to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-08-26 · tag F0657 — failed to keep the care plan current — widespread
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 12 of 12 residents (Resident #1, Resident #10, Resident #11, Resident #12, Resident #14, Resident #15, Resident #19, Resident #22, Resident #23, Resident #28, Resident #40, and Resident #193) reviewed for care plans. The facility failed to ensure resident care plans were developed and updated within 7 days following the completion of the MDS as well as having an Intradisciplinary Team present and at the care conference and involved in the care planning process. This failure could place residents at risk of not have having their care plans completed accurately and timely. Findings include: 1. Record review of Resident #1's face sheet revealed an [AGE] year-old male who was admitted to the facility 06/07/2023 and readmitted on [DATE]. Resident #1 had diagnoses which included chronic venous hypertension (increased pressure in your veins), dysphagia…

    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 · Ecited before2023-08-26 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 3 of 3 months (January, FebruaryFebruary, and March 2023) reviewed for nursing services. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours on ten weekends January, February, and March 2023 This failure placed could place the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings included: Record review of the facility's nursing schedule for RN coverage for January 2023, February 2023, and March 2023 revealed, the Director of Nurses worked Monday through Friday. The schedule did not reflect another RN working during that time period. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours on Sunday 01/01/2023, Saturday…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-26 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to a comprehensive assessment was completed within 14 days after the facility determined or should have determined, that there was a significant change in the resident's physical condition or mental condition for 2 of 10 residents (Residents #14, and Resident #40) reviewed for assessments. The facility failed to capture a comprehensive MDS assessment after Resident # 14 and Resident #40 had a significant decline and a hospital stay. This failure could place residents at risk for not being assessed for a change in condition and the need to revise their care plans to address changes in condition and develop interventions to meet their needs for care assistance and treatments. The findings include: 1. Record review of Resident #14's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #14 had diagnoses which included Chronic obstructive pulmonary disease (decreased airflow to the lungs),…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-26 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 15 sampled residents (Residents #'s 12) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #12's MDS was accurately coded as receiving dialysis. 2. The facility failed to ensure Resident #12's MDS continence status was accurately . This failure could place residents at risk of not receiving the proper care and services due to inaccurate records. Findings include: Record review of Resident #12's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #12 had diagnoses which included retention or urine (not able to urinate properly), acute kidney failure (kidney is unable to filter waste), Type 2 diabetes mellitus (body does not produce enough insulin) and cerebral infarction (disrupted blood flow to the brain to due problems in the blood vessels). Record review of Resident #12's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-26 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 2 residents, (Resident #11) reviewed for PASRR Level 1 screenings. The facility did not correctly identify Resident #11 as having a mental illness and did not complete a new PASRR Level One Screening. This failure could place residents at risk of not being evaluated for PASRR services. The findings were: Record review of Resident #11's face sheet, dated 08/25/2023, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #11's had diagnoses which included Mood disturbance (decreased blood flow to the brain that causes mood disturbances), bipolar (mental disorder that is characterized by mood swings that last more than 2 weeks), and depression (state of sadness). Record review of Resident #11 Physician Orders, dated 08/25/2023, revealed orders for olanzapine; 5…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-26 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a base line care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of the resident's admission for 1 of 5 residents (Resident #19) whose records were reviewed in that: for care plans. The facility failed to ensure Resident #19 had a base line care plan developed and implemented upon admission on [DATE]. This failure could place the residents at risk for not receiving care and services required to meet their individual needs from the date and time they were admitted to the facility. The findings included: Record review of Resident #19's face sheet, dated 08/24/2023, revealed resident was a [AGE] year-old male, who was initially admitted to the facility on [DATE]. Resident #19 had diagnoses which Diagnosis included: cerebral palsy (congenital disorder of movement due to abnormal brain development),…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-26 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to maintain clinical records that were complete and/or accurate for 1 of 1 (Resident #40) residents reviewed for clinical records in that: The facility staff were unable to locate documentation in Resident #40s clinical record regarding when to remove surgical staples. This failure could place residents at risk of not having care needs met The findings include: In an interview on 08/23/2023 at 9:32 AM, Resident #40 said he did not receive any type of care for his surgical wound until after he came back from the hospital on [DATE] with an infection of his wound. In an interview on 08/24/2023 at 9:20 AM, the DON said there was documentation for the staples to be removed in 7 to 10 days. When asked to provide the documentation, the DON stated she was too busy training a new agency nurse . She revealed she was ultimately responsible in ensuring the documentation was correct and updated. In an interview on 08/24/2023 at 9:25 AM with the Administrator, she said…

    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

“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

$23,813 in federal fines across 1 penalty.

  • $23,813 — penalty dated 2023-08-26

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 AVIR HEALTH GROUP — 116 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 4 of 52.3+1.7 vs chain
Health inspection 3 of 52.4+0.6 vs chain
Staffing 2 of 51.8+0.2 vs chain
Quality measures 5 of 53.6+1.4 vs chain
The other 115 homes this chain runs (chain average 2.3★, per CMS)
1 of 5Avir At BanderaBandera, TX 1 of 5Avir At Cowhorn CreekTexarkana, TX 1 of 5Avir At DallasDallas, TX 1 of 5Avir At LindaleLindale, TX 1 of 5Avir At StephenvilleStephenville, TX 1 of 5Avir at AdamsTemple, TX 1 of 5Avir at Arbor TerraceSan Angelo, TX 1 of 5Avir at BeaumontBeaumont, TX 1 of 5Avir at BeltonBelton, TX 1 of 5Avir at BoerneBoerne, TX 1 of 5Avir at BradburnGrand Saline, TX 1 of 5Avir at CaldwellCaldwell, TX 1 of 5Avir at Camp WoodCamp Wood, TX 1 of 5Avir at Citizens TrailTexarkana, TX 1 of 5Avir at ConverseConverse, TX 1 of 5Avir at GainesvilleGainesville, TX 1 of 5Avir at GarlandGarland, TX 1 of 5Avir at GiddingsGiddings, TX 1 of 5Avir at Heritage OaksLubbock, TX 1 of 5Avir at HillsboroHillsboro, TX 1 of 5Avir at HoustonHouston, TX 1 of 5Avir at Johnson CityJohnson City, TX 1 of 5Avir at KennedaleKennedale, TX 1 of 5Avir at KerrvilleKerrville, TX 1 of 5Avir at LongviewLongview, TX 1 of 5Avir at LubbockLubbock, TX 1 of 5Avir at Meadow CreekSan Angelo, TX 1 of 5Avir at MineolaMineola, TX 1 of 5Avir at New BraunfelsNew Braunfels, TX 1 of 5Avir at PatriotEl Paso, TX 1 of 5Avir at PortlandPortland, TX 1 of 5Avir at Rose TrailTyler, TX 1 of 5Avir at San AngeloSan Angelo, TX 1 of 5Avir at SeguinSeguin, TX 1 of 5Avir at TexarkanaTexarkana, TX 1 of 5Avir at Tierra EsteEl Paso, TX 1 of 5Avir at Veterans MemorialHouston, TX 1 of 5Avir at WestonTemple, TX 1 of 5Avir at WinnsboroWinnsboro, TX 1 of 5Avir at WoodlandsEastland, TX

Showing 40 of 115; 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
JACK COUNTY HOSPITAL DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/30/2014
211 E JASPER STREET PROPERTY OWNER LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 03/01/2025
WELLTOWER NNN GROUP, LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 03/01/2025
WELLTOWER OP, LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 03/01/2025
WELLTOWER INCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 03/01/2025
BEAMAN, FRANKIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 01/01/2008
LEE, KIMIndividualCORPORATE DIRECTORsince 01/01/2022
211 E JASPER STREET OPCO LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
JACKSBORO NURSING OPERATIONS, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2018
THCM, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2018
BRITTAIN, JACEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/12/2023
JAMAL, SYEDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025

CMS files one row per role, so the 20 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

8 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.

$3.8M
Net patient revenuemost recent cost report
+13.4%
Operating marginrevenue minus expenses
$1
Related-party expense0% of expenses
Who pays — share of resident-days
Medicaid 78%Medicare 12%Other / private 10%

About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1 paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$229per resident / day
operating cost
$6,947per month
≈ monthly operating cost
$264per day
avg. revenue, all payers

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

What families pay in TX

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 455808. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, 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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