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Oakmont Healthcare and Rehabilitation Center of Ka

1525 Tull Dr, Katy, TX 77449 · For profit - Corporation · 130 certified beds · (281) 578-1600 Medicare & Medicaid certified

Call the home — (281) 578-1600 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Nov 20241 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$8,281 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,281 in federal fines (most recent 2025-10-06)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (93%) 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.

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 3 of 5

Location & what’s nearby

Urgent care / clinic
21814 Katy Freeway, Suite 210 · (713) 468-2030 · Call to confirm hours
Pharmacy
21501 Park Row Dr Ste 200 · (281) 698-6100 · Call to confirm hours
Grocery
21811 Katy Fwy · (346) 322-4178 · Call to confirm hours
Park
700 Westgreen Blvd · (832) 978-0906 · Typically dawn to dusk
Place of worship
20910 Park Row Dr · (281) 578-3535

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 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 fell from 4 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 increased14.2%15.8%15.4%typical
Long-stay residents who lose too much weight2.5%3.0%5.4%better
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 infection2.0%0.8%2.0%typical
Long-stay residents with depressive symptoms1.7%2.4%6.5%better 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 injury2.8%3.3%3.3%better
Long-stay residents whose ability to walk worsened12.7%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication3.7%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers5.1%3.8%4.7%typical
Long-stay residents with worsening bladder/bowel control14.0%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table12.0%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%88.0%79.4%better
Short-stay residents rehospitalized after admission27.9%25.7%22.6%worse
Short-stay residents with an outpatient ER visit6.7%12.3%12.0%better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

46.0% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.0%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
0.34U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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 SNF46.0%CMS range 27.1–60.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 7.6–15.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were 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 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 stay0.0%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 SNFs1.181.02Oct 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

0.52
RN hours/ resident / day
0.65
LPN hours/ resident / day
1.74
Aide hours/ resident / day
2.91
Total nurse hours/ resident / day
0.45
RN hoursweekends
92.6%
Total nursing turnover
100.0%
RN turnover

How full it usually is: this home is certified for 130 beds and averages 69.4 residents a day — about 53% occupied, or roughly 61 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 2.91 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.74 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 2.62 hrs/resident/day on weekends vs 3.02 on weekdays — 14% thinner on weekends. RN hours go from 0.54 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 93% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

11
deficiencies at the latest standard inspection (2026-02-26)
10
at the previous standard inspection (2024-11-15)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Immediate jeopardy · J2025-10-06 · 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 assistive devices to prevent accidents for 1 of 5 (Resident #1) residents reviewed for accidents and supervision. The facility failed to ensure that CNA B provided the necessary care and supervision to Resident #1 by ensuring CNA B did not sleep when providing 1:1 supervision to Resident #1 who has a history of falls with injury, including a recent subdural hematoma, CT scan done on 9/12/2025 showed the worsening as indicative by the findings as it noted significant interval change developed of hemorrhage since prior examination, there is a mixed density left subdural hematoma overlying the left cerebral convexity measuring up to 1.0 cm in thickness increased in size compared to 8/21/25 when measure 0.7 cm.The noncompliance was identified as Past Non-Compliance. The PNC IJ began on 09/12/2025 and ended on 09/12/2025. The facility corrected the noncompliance before the survey began.…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · E2026-02-26 · 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 residents have a right to a dignified existence and treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 (Resident #41) of 18 residents reviewed for dignity.-RN Z was providing Resident #41's bolus feeding with the door open and blinds opened on 02/25/2026.- RN Z did not provide Resident #67 privacy during insulin administration on 02/25/26.-LVN AF did not provide privacy during medication administration via G Tube to Resident #30 on 2/24/26These deficient practices could lead to psychosocial harm due to feelings of low self-esteem and/or embarrassment regardless of resident cognition. Resident #41Record review of Resident #41's face sheet last captured 02/26/2026, she was an [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnosis was gastronomy 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-26 · tag F0641 — pattern
    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, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the residents' status for 2 of 18 residents (CR #75 and Resident #60) whose assessments were reviewed, in that:-CR#75's behavior was not reflected on her initial MDS dated [DATE]. -Resident #60's fall on 10/15/2026 was not documented in her most recent quarterly MDS assessment on 11/29/2026.These failures could place residents at-risk of not receiving the care and services to prevent aggressive behavior or injury due to inaccurate assessments. #75 Record review of CR#75's clinical records dated 2/24/2026 revealed she was a 76-year female who was admitted to the facility on [DATE]. Her diagnoses included Non-Alzheimer's dementia (memory loss), dysphagia (swallowing difficulties), depression (feeling of unhappiness and hopelessness), respiratory failure (condition where the blood does not have enough oxygen or too much carbon dioxide), pain (unpleasant sensory and emotional experience with tissue…

    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 · E2026-02-26 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 20%, based on 7 errors out of 35 opportunities, which involved 2 of 7 residents (Resident #30, and Resident #6) and --2--- of ---3-- staff observed during medication administration reviewed for medication errors. 1. LVN AF failed to administer Polyvinyl Alcohol-Povidone PF Ophthalmic Solution 1.4-0.6 % (used to temporarily relieve dry, burning, itchy, or irritated eyes by wind, sun or environment) lower high fluid pressure inside the eye) Ophthalmic Solution 0.5 % eyedrops ophthalmic drops, on 2/24/26, initialed as given to Resident #30, when it was not given.2. LVN AF failed to administer Protonix Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tab (used to treat gastric reflux) on 2/24/26, initialed as given to Resident #30, when it was not given. 3. LVN AF failed to administer QUEtiapine Fumarate Oral Tablet 50 MG…

    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 before2026-02-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.1. The facility failed to ensure leftover food past the use date was discarded. 2. The facility failed to ensure leftover food to be used later was stored at a safe temperature.3. The facility failed to ensure frozen food thawed properly. 4. The facility failed to put sufficient sanitizing solution in the 3-sink compartment in the kitchen.5. The facility failed to fix broken tiles in the kitchen.6. The facility failed to store in a separate container a scoop used for food bins in the kitchen storeroom.7. The facility failed to ensure food was stored 6 inches off the floor These failures could place residents t risk of foodborne illness, disease from food handling and pest or vermin. Observation of the facility kitchen on 02/24/2026 at 8:45 AM revealed the following. 1. Thawing frozen chicken in an 8-inch-deep bucket, immersed in water that was 78 degrees…

    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 before2026-02-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 7 of 12 residents ( Residents #6, #30, #28, #15 #7, #35 and #5) and 5 of 5 staff (CNA J, MA T, LVN AF ,RN W, RN CC ) and 1 of 2 linen closets (Linen Closet B) reviewed for infection control. 1. RN CC failed to wipe the blood pressure cuff between Resident #7, Resident #35 and Resident #5 on 2/24/26.2. MA T failed to wipe the blood pressure cuff between Resident #28 and Resident #15 on 2/24/26.3. LVN AF failed to wear PPE when administering Resident #30's G-Tube medications, who was on EBP, on 2/24/26.4. RN W failed to wear PPE when administering Resident #6's G-Tube medications, who was on EBP, on 2/24/26.5. The facility failed to ensure CNA J cleaned in between and around Resident #4's buttocks and failed to open…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-26 · 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 observation, record review and interviews, the facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for 2 of 18 residents (Residents #57 and CR#75) reviewed for care plans. The facility did not review and update Resident #57's care plan when he had an 18.8 pounds weight loss.The facility did not review and update CR #75's care plan when she had behaviors of refusing care, throwing things on the floor, hitting walls and throwing stuff on the floor. These failures could place residents with weight loss and behavior issues from getting the care and services that could improve their quality of life. Resident #57Record review of Resident #57's clinical records dated 2/25/2026 revealed he was a 73-year male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Alzheimer's disease (is brain disorder that affects memory, thinking and behavior), and dysphagia (swallowing difficulties),. 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    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 the necessary services to maintain, grooming, and personal hygiene for 1 of 3 residents (Resident #4) reviewed for ADL care. The facility failed to ensure CNA J cleaned Resident #4 in a timely manner on 2/26/26. This failure could place residents at risk for pain, infection and hospitalization.Record review of Resident #4's face sheet, dated 2/24/2026, reflected the resident was [AGE] years old, female, and admitted to the facility on [DATE] with diagnoses of urinary tract infection and stage 3 sacral pressure ulcer. Record review of Resident #4's quarterly MDS, dated [DATE], reflected the BIMS score was 3 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #4 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who was incontinent of bladder and bowel received appropriate treatment and services for 1 of 3 residents (Residents #4) reviewed for incontinent care, in that: CNA J did not open Resident #4's labia to clean during incontinent care on 2/26/26. This failure could place residents at-risk for infection due to improper care practices. Record review of Resident #4's face sheet, dated 2/24/2026, reflected the resident was [AGE] years old, female, and admitted to the facility on [DATE] with diagnoses of urinary tract infection and stage 3 sacral pressure ulcer. Record review of Resident #4's quarterly MDS, dated [DATE], reflected the BIMS score was 3 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #4 was incontinent 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-26 · 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 restore, if possible, oral eating skills and prevent complications of enteral feedings including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 2 of 3 residents (Resident #30, #6) reviewed for feeding tubes. -The facility staff failed to ensure LVN AF allow medication and feed flow by gravity. Resident #30's medication and feeding was plunge via G tube and LVN AF did not flush GTube with water before and after medication 2/24/26. -The facility staff failed to ensure RN W allow medication and water flow by gravity. Resident #6's medication was plunged into GTube on 2/24/26. This failure could place residents at risk for complications such as aspiration pneumonia (occurs when food or liquid is breathed into the airway or lungs, instead of being swallowed),…

    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 · D2026-02-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Nurses Cart East Wing) reviewed for medication storage. The facility failed to ensure the East Wing nurse medication cart did not contain opened and undated medication. This failure could place residents at risk of receiving expired medication and improperly stored medications which could result in delayed healing. During an observation on [DATE] at 4:44 PM of the nurse medication caret for the East Wing revealed the following opened medications were not dated when they were opened: The following eye drops were open with no date:1. Ciprofloxacin Ophthalmic2. Refresh Tears3. Cipri Dexa [NAME] 0.3-0.1 Interview with RN Z on [DATE] at 4:44 PM revealed she was not aware of 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2026-02-26 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 policies and procedures to ensure the resident's medical record included documentation that indicated, at minimum that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal for 1 of 5 residents (Resident #8) reviewed for immunizations.The facility failed to ensure Resident #8 had record of receiving education or being offered the pneumococcal vaccine. This failure could cause residents to be vulnerable to preventable illnesses. Record review of Resident #8's face sheet, dated 02/26/2026, reflected an [AGE] year-old female who was originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included chronic congestive heart failure, unspecified dementia…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-06 · 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 interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 5 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1's weight was accurately documented on the admission MDS dated [DATE]. This failure could place residents with weight loss or gain at risk by not receiving care and intervention that could meet their weight needs. Record review of Resident #1's face sheet dated 09/17/2025 reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident#1's diagnoses included intracranial injury with loss of consciousness (a brain injury that causes a person to lose awareness of their surrounding and body), traumatic subdural hemorrhage with loss of consciousness status unknown ( a serious medical condition where a collection of blood forms between the brain and the inner layer of the [NAME] (dura mater) causing pressure on the brain and loss of conscious),…

    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 · F2024-11-15 · tag F0814 — failed to dispose of garbage properly — widespread
    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 the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpster reviewed for food and nutrition services. -The facility failed to ensure the dumpster door was closed at all times when no one was dumping garbage. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 11-12-24 at 8:45 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster ¾ full of garbage and the dumpster door was open. In an interview on 11-12-24 at 8:45 am, with the Director of Food and Nutrition, she stated the dumpster door should not be left open when not in use to prevent bugs, flies, rodents getting in the dumpster and from entering facility. She stated housekeeping, and nursing also discarded their waste garbage in the dumpster. It was the responsibility of staff from dietary, nursing and housekeeping for ensuring the dumpster doors are kept closed when not in use. Interview with the Administrator on…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-15 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 4 of 8 residents (Resident #45, Resident #175, Resident #9 and Resident #5,) reviewed for privacy, in that: 1. CNA (certified nursing aid) C failed to place Resident #45 Foley catheter bag inside of a privacy bag. 2. CNA L failed to place Resident #175 Foley catheter bag inside of privacy bag. 3. The facility failed to provide privacy curtain between Resident #9 and Resident #5's bed to identify a separation of space and privacy between the two residents. These failures placed residents at risk for embarrassment, at risk of loss of dignity and decrease in quality of life. The findings include: Resident #45: Record review of Resident #45's factsheet dated 10/15/2024 revealed a [AGE] year-old male admitted to the NF on 09/09/2024. Resident #45's diagnoses included the following: chronic kidney disease, functional quadriplegia (to be completely unable to move due to severe disability from…

    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 · Ecited before2024-11-15 · 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 observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. The facility failed to ensure foods were dated as opened/prepared discarded after used by date /time. These failures could place residents at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen refrigerator on 11/12/24 at 8:15 AM revealed the following: 1. An open box of cream cheese dated 10/30/24 with no use date 2. Sliced deli meat in a plastic bag in the refrigerator dated 11/01/24 3. Sliced Swiss Cheese in a plastic bag in the refrigerator dated 11/01/24 4 Shredded Mozzarella cheese in a plastic bag in the refrigerator dated 10/15 5. Shredded Mozzarella cheese in a plastic bag in the refrigerator dated 11/06/24 6. Sliced deli ham in a plastic bag in the refrigerator and no label no date. 7. Canned beets in a plastic container in the refrigerator dated 11/05/24 and a use by date of 11/12/24 8. Beef stew in…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-15 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 report the results of all investigations to the State Survey Agency, within 5 working days of the incident for an allegation of abuse to report for 1 of 4 residents (Resident #61) reviewed for abuse/neglect in that: -Resident #61 had an incident with an allegation of abuse on 09/3/2024. The facility did not submit the final 3613 facility investigation report to the State Agency within 5 working days. This failure could place residents at risk of having allegations of abuse, neglect, exploitation not being investigated or reported to the State agency. Findings Include: Record review of the admission record dated October 17, 2024. revealed that Resident #61 was an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis after cerebral infarction (related conditions that cause weakness or paralysis on one side of the body) and need for assistance with personal care (a physical, cognitive, or…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-15 · 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 observation, interview, and record review, the facility failed to have a person-centered comprehensive care plan developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for 1 of (Resident #42) 6 residents reviewed for care plans. - Resident #42's comprehensive centered care plan revealed that resident was not being care planned for foot care. This failure placed resident at risk for not having their individual medical needs met. Findings Included: Record review of Resident #42's face sheet dated 11/15/2024 revealed a [AGE] year-old male admitted to the NF on 10/04/2023. Resident diagnoses included Alzheimer's Disease (disease that destroys memory and other mental functions), cerebral infarction (when blood flow to the brain is blocked), hemiplegia and hemiparesis (condition that causes paralysis or weakness), and type 2 diabetes mellitus (long term condition where the body has trouble controlling blood sugar and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-15 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents received proper treatment and care to maintain mobillity and good foot health for 1 (Resident # 42) pf 6 residents reviewed for foot care. -The facility failed to provide Resident #42 who had diabetes mellitus podiatry services. This failure placed resident at risk for injuries, infections, unwanted hospitalization, and amputation leading to a decrease in quality of life. Findings Included: Record review of Resident #42's face sheet dated 11/15/2024 revealed a [AGE] year-old male admitted to the NF on 10/04/2023. Resident diagnoses included Alzheimer's Disease (disease that destroys memory and other mental functions), cerebral infarction (when blood flow to the brain is blocked), hemiplegia and hemiparesis (condition that causes paralysis or weakness), and type 2 diabetes mellitus (long term condition where the body has trouble controlling blood sugar and using it for energy). Record review of Resident #42's admission…

    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 · D2024-11-15 · 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 and services, including oxygen administration was provided such care, consistent with professional standards of practice for 1 of 4 residents (Resident #20) reviewed for respiratory therapy in that: 1. The facility failed to ensure Resident #20's oxygen was set according to physician's orders. This failure could place residents at risk of respiratory distress. The findings were: Record review of Resident #20's sheet dated 11/15/2024 revealed a [AGE] year-old female was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #20 had diagnoses included: cerebral infarction (when blood flow to the brain is disrupted, causing brain tissue damage.), hypertension (when the blood pressure in the blood vessels is too high), and cerebrovascular disease (condition [NAME] affect the blood vessels and blood flow in the brain and spinal cord). Record review of Resident #20'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-15 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 7 residents (Residents #43) reviewed for significant medication errors. 1. MA Y failed to administer medications as ordered to Resident #43 by attempting to administer Carvedilol 3.125mg outside of ordered parameters. This failure could place residents at risk of decrease pulse, and potential hospitalization. The findings were: Record review of Resident #43's face sheet dated 11/14/2024 revealed an [AGE] year-old female was admitted to the facility on [DATE]. Resident #43 had diagnoses included: paroxysmal atrial fibrillation (short or sudden episodes of an irregular heart usually start and stop on their own), hypertension (when the blood pressure in the blood vessels is too high), and angina pectoris (chest pain or discomfort that occurs when a part of the heart doesn't get enough blood or oxygen). Record review of Resident #43's quarterly MDS assessment 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #45, Resident #9 and Resident #5) of 8 residents reviewed for infection control. 1. The facility failed to have infection control signage on Resident #45's door entrance to alert staff and visitors in preventing the development and transmission of infections. 2. The facility failed to label and store Resident #9's personal care item at sink area of a semi-private room shared with Resident #5. These failures placed residents, staff and visitors at risk for cross contamination, unwanted infections, and decease in quality of life. Findings Resident #45 Record review of Resident #45's factsheet dated [DATE] revealed a [AGE] year-old male admitted to the NF on [DATE]. Resident #45 diagnoses included the following: chronic…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-06 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 services that meet professional standards of quality as outlined by the comprehensive care plan for 1 (Resident #1) of 13 residents reviewed for services. -The facility failed to provide weekly skin assessments for Resident #1 for 2/12/2024 through 3/2/2024, 3/27/24 through 4/13/2024, and 04/27/2024 through 5/11/2024. This failure could put residents at risk of infection, skin breakdown, pain, and lead to further health complications due to not being regularly assessed, monitored, and treated in a timely manner. Findings included: Record review of Resident #1's face sheet last updated 11/04/2024 revealed an [AGE] year-old male originally admitted on [DATE] and last readmitted on [DATE]. Resident #1's medical diagnoses included: muscle weakness, need for assistance with personal care, Type 2 Diabetes Mellitus (excessive sugar in the blood), lower back pain, Major Depressive Disorder, Anxiety Disorder, and a history of stroke (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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-06 · 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 (ADLs) received the necessary services to maintain good personal hygiene, for 1 of 19 (Resident #1) reviewed for ADLs as evidenced by: -CNA A failed to provide bowel and bladder incontinent care for Resident #1 for over 7 hours. This failure placed resident at risk for skin break down, infections, hospitalization, and decrease in quality of life. Findings included: Record review of Resident #1's face sheet dated 11/05/2024 revealed an [AGE] year-old male admitted to the NF on 11/01/2023. Resident diagnosis included the following: cerebral infarction (when blood flow to the brain is blocked), need for assistance with personal care, paralytic syndrome (weakness, muscle wasting, and loss of reflexes), depression, type 2 diabetes mellitus (when the body has trouble controlling blood sugar and using it for energy), and myopathy (disease that affects the muscles 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 before2024-10-14 · 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 observations, interviews, and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 7 residents (Resident #1) reviewed for medication administration. -The NF DON failed to transcribe physician orders received from hospice on 10/08/2024 until 10/10/2024. -LVN A failed to follow-up to see if there was an order for the medication, morphine 15mg, delivered to the NF on 10/08/24 for Resident #1. Resident #1 did not receive the morphine that was available to him at the facility on 10/8/24 until 10/10/24. This failure placed Resident #1 at risk for unwanted pain, discomfort, and decrease in quality of life. Findings: Record review of Resident #1's face sheet revealed a [AGE] year old male admitted to the NF originally on 07/25/2023 with diagnoses that included the following: dementia (loss of memory), history of falling, muscle weakness, heart disease, type 2 diabetes mellitus (body has trouble controlling blood sugar and using it for energy),…

    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 before2023-09-28 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 8 residents (Resident #2) reviewed for pharmaceutical services. The facility failed to ensure Morphine (pain medication) Extended Release (ER) (medication was formulated so the drug was released slowly over time) tablet was administered without crushing according to pharmacy packet instruction. This failure could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment. Findings include: Record review of Resident #2s dated 09/27/2023 face sheet revealed she was a [AGE] year-old female admitted on [DATE] and readmitted [DATE], with multiple sclerosis ( A disease in which the immune system eats away at the protective covering of nerves), pain, Dysphagia (difficulty swallowing), contracture…

    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
  • No harm found · C2024-11-15 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    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 post in a place readily accessible to residents, family members, and legal representative of residents, the results of the most recent survey of the facility. 1. The facility failed to ensure the posting location of the previous year's surveys, certifications, and complaint investigations with plan of correction were posted in a public location for residents, family members, and visitors to review. The failure placed residents and their family members and representatives at risk for violation of the right to review the findings from State surveys and investigations conducted in the facility without asking to review the reports. Findings included: During an observation on 11/13/2024 at 10:34 a.m. the last survey results dated 09/28/2023 were in a binder at the front desk outside of ADMN's (administrator) office. During an interview on 11/13/2024 at 10:04 a.m., during the confidential group meeting, residents stated they were unaware of the location of the previous state inspection survey reports. During 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.

    Resident Rights 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

$8,281 in federal fines across 1 penalty.

  • $8,281 — penalty dated 2025-10-06

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 CREATIVE SOLUTIONS IN HEALTHCARE — 149 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 52.1-0.1 vs chain
Health inspection 3 of 52.7+0.3 vs chain
Staffing 1 of 51.1-0.1 vs chain
Quality measures 3 of 53.2-0.2 vs chain
The other 148 homes this chain runs (chain average 2.1★, per CMS)
1 of 5Afton Oaks Nursing and Rehabilitation CenterHouston, TX 1 of 5Arlington Heights Health and Rehabilitation CenterFort Worth, TX 1 of 5Beltline Healthcare CenterGarland, TX 1 of 5Bluebonnet Nursing & RehabilitationKarnes City, TX 1 of 5Bluebonnet Point WellnessBullard, TX 1 of 5Brentwood Terrace Healthcare And RehabilitationParis, TX 1 of 5Buena Vida Nursing and Rehab-San AntonioSan Antonio, TX 1 of 5Cottonwood Nursing & RehabilitationDenton, TX 1 of 5Countryview Nursing & RehabilitationTerrell, TX 1 of 5Dogwood Trails ManorWoodville, TX 1 of 5Downtown Health and Rehabilitation CenterFort Worth, TX 1 of 5Estates Healthcare and Rehabilitation CenterFort Worth, TX 1 of 5Fair Park Health & Rehabilitation CenterDallas, TX 1 of 5Five Points Nursing & Rehabilitation of College StCollege Station, TX 1 of 5Five Points at Lake Highlands Nursing and RehabDallas, TX 1 of 5Five Points of PflugervillePflugerville, TX 1 of 5Franklin Heights Nursing & RehabilitationEl Paso, TX 1 of 5Gilmer Nursing & RehabilitationGilmer, TX 1 of 5Grace Pointe Wellness CenterEl Paso, TX 1 of 5Graham Oaks Care CenterGraham, TX 1 of 5Granbury Care CenterGranbury, TX 1 of 5Greenhill VillasMount Pleasant, TX 1 of 5Heritage At Longview Healthcare CenterLongview, TX 1 of 5Huebner Creek Health & Rehabilitation CenterSan Antonio, TX 1 of 5Interlochen Health and Rehabilitation CenterArlington, TX 1 of 5Kenedy Health & RehabilitationKenedy, TX 1 of 5Kennedy Health & RehabLufkin, TX 1 of 5Lake Lodge Nursing & RehabilitationLake Worth, TX 1 of 5Lampstand Nursing and RehabilitationBryan, TX 1 of 5Lancaster Nursing & RehabilitationLancaster, TX 1 of 5Marine Creek Nursing & RehabilitationFort Worth, TX 1 of 5Mesa Vista Inn Health CenterSan Antonio, TX 1 of 5Mountain View Health & RehabilitationEl Paso, TX 1 of 5Navasota Nursing & RehabilitationNavasota, TX 1 of 5Normandy Terrace Nursing & Rehabilitation CenterSan Antonio, TX 1 of 5North Pointe Nursing and RehabilitationWatauga, TX 1 of 5Park Place Care CenterGeorgetown, TX 1 of 5Parkview Manor Nursing and RehabilitationWeimar, TX 1 of 5Peach Tree PlaceWeatherford, TX 1 of 5Pebble Creek Nursing CenterEl Paso, TX

Showing 40 of 148; 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 / managerTypeRoleSince
FRELS, JOHNIndividualCORPORATE DIRECTORsince 11/04/2014
PAPACEK, CHARLESIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 10/01/1997
SHEPPARD, ANNAIndividualCORPORATE DIRECTORsince 05/01/2019
SHEPPARD, CYNTHIAIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 06/25/2013
WHEELER, RICHARDIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 07/27/2010
FALCONE, LYNNIndividualCORPORATE OFFICERsince 05/16/2015
WEISHAAR, MATTHEWIndividualCORPORATE OFFICERsince 12/01/2003
BOOKER, MARILYNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/27/2020

CMS files one row per role, so the 11 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$5.7M
Net patient revenuemost recent cost report
-26.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 73%Medicare 3%Other / private 24%

About 73% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$297per resident / day
operating cost
$9,014per month
≈ monthly operating cost
$235per day
avg. revenue, all payers

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

What families pay in TX

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 455703. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-26, 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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