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Laredo South Nursing And Rehabilitation Center

1100 Galveston St, Laredo, TX 78040 · Non profit - Corporation · 112 certified beds · (956) 723-2068 Medicare & Medicaid certified

Call the home — (956) 723-2068 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$8,021 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2025
  • 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 $8,021 in federal fines (most recent 2024-05-10)

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 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1101 Corpus Christi St · (956) 727-8470 · Call to confirm hours
Pharmacy
Walgreens0.3 mi
1119 Guadalupe St · (956) 727-0178 · Call to confirm hours
Grocery
1301 GUADALUPE ST.
Park
108 W Guerrero St · Typically dawn to dusk
Place of worship
1419 Hendricks Ave

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 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 3 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 increased16.5%15.8%15.4%typical
Long-stay residents who lose too much weight6.8%3.0%5.4%worse
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 infection2.1%0.8%2.0%typical
Long-stay residents with depressive symptoms1.8%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 injury2.5%3.3%3.3%better
Long-stay residents whose ability to walk worsened11.4%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.5%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine98.5%98.0%95.3%typical
Long-stay residents with pressure ulcers2.5%3.8%4.7%better
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 table6.1%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine91.9%88.0%79.4%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.

31.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

31.7%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
0.26U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 SNF31.7%CMS range 19.6–46.151.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 7.5–16.610.7%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 identifiednot 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 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.9%CMS range 5.6–14.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.671.02Oct 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

0.70
RN hours/ resident / day
0.63
LPN hours/ resident / day
1.87
Aide hours/ resident / day
3.19
Total nurse hours/ resident / day
0.32
RN hoursweekends
36.7%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 112 beds and averages 68.1 residents a day — about 61% occupied, or roughly 44 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 3.19 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 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 2.61 hrs/resident/day on weekends vs 3.43 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.86 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2025-07-22)
6
at the previous standard inspection (2024-06-26)

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.

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

  • Immediate jeopardy · J2024-05-10 · 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 observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one resident (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 eloped from the facility during lunch time. This failure could place residents requiring supervision at risk for injury and accidents with potential for more than minimal harm. The noncompliance was identified as Past Non-Compliance. The IJ began on 10/17/23 and ended on 10/18/23. The facility had corrected the noncompliance before the investigation began. Findings included: Record review of Resident #1's face sheet dated 5/09/24 reflected an [AGE] year-old-female with an original admission date of 1/19/22. Diagnosis included type two diabetes (insufficient insulin production in the body), acute (sudden) kidney failure, and dementia (mental decline that affects the quality of daily living). Record review of Resident…

    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 · D2026-06-30 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #1) of four residents reviewed for call light placement. The facility failed to ensure Resident #1's call light was within reach on 06/29/26. This failure could place residents at risk for needs and accommodations being unmet and a delay in care.Record review of a face sheet dated 6/29/2026 indicated Resident #1 was a [AGE] year-old male, initially admitted on [DATE] and last re-admitted on [DATE], diagnoses included Hypertensive Heart Disease without heart failure (heart damage or structural changes caused by long-term high blood pressure), Epileptic seizures related to external causes (sudden temporary bursts of abnormal electrical activity in the brain that disrupt normal communication between nerve cells), depression, Hemiplegia (the complete or partial paralysis of the entire side of the body) and hemiparesis (partial weakness or reduced control 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-07-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food per professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation, and sanitation.The facility failed to ensure dishes were cleaned after washing and not used for service.The facility failed to ensure the utensils were in good condition.The facility failed to ensure personal items were not in the prep areas.The facility failed to ensure a cabinet door was safe to open.The facility failed to ensure table scraps were disposed of properly.The facility failed to ensure personal items were separated from leftovers in refrigerator #D2.The facility failed to ensure food items in refrigerators #A1, and #D2, and freezers #B3, #C3, and #D2 were labeled, dated, and stored properly.The facility failed to ensure the dry storage area was free from fruit and dented cans.The facility failed to ensure food items in the dry storage area were properly sealed, labeled, and dated. The facility failed to properly maintain temperature logs 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 · E2025-07-22 · 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

    Based on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 2 glucometers (device used to measure the amount of glucose in a resident's blood) reviewed for pharmacy services. The facility failed to ensure the glucometer in the nurse cart for halls 100, 200 and 400 were tested for accuracy and recorded in the glucometer logbook on 07/01/25, 07/02/25, 07/07/25, 07/08/25, and 07/21/25 in the month of July. These failures could place residents at risk of receiving either too much insulin or not enough. The findings included:Record review of the glucometer logbook on 07/22/25 at 10:37 AM revealed the test results for the glucometer in the nurse cart for halls 100, 200 and 400 were not recorded on 07/01/25, 07/02/25, 07/07/25, 07/08/25, and 07/21/25. In an interview with the DON on 07/22/25 at 1:11 PM, the DON stated the glucometers were supposed to be tested every day on the night shift by the nurses and the results recorded 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-22 · tag F0583 — failed to protect personal privacy — isolated
    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 the resident's right to privacy for 1 (Resident #5) of 17 residents reviewed for privacy. The facility failed to ensure the WCN provided privacy for Resident #5 while performing his wound care. This failure could cause residents to feel uncomfortable, disrespected, and possibly a loss of dignity due to a lack of privacy. The findings include:Record review of Resident # 5's face sheet dated 07/21/25 reflected an [AGE] year-old-male with an original admission date of 09/09/24. Diagnoses included congestive heart failure, high blood pressure, type two diabetes (insufficient production of insulin in the body), and pressure ulcer (a localized injury to the skin and underlying tissue caused by prolonged pressure) at an unspecified site and location. Record review of Resident #5's physician orders dated 07/20/25 reflected: Cleanse Sacrum (triangular bone at the base of the spine. Upper cack part of the pelvic cavity) with normal saline,…

    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 · Dcited before2025-07-22 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one resident (Resident #7) of 17 residents whose care plans were reviewed. The facility failed to ensure Resident #7's comprehensive care plan was updated was developed and implemented after starting anticoagulant (blood thinner) medication on 04/26/25. The deficient practice could place residents in the facility at risk of not being provided with the necessary care or services, and the implementation of personalized plan of care developed to address their specific needs. Findings include:Record review of Resident #7's face sheet dating 07/20/25 reflected a [AGE] year-old-male with an original admission date of 1/07/20. Diagnoses included pulmonary fibrosis (lung disease characterized by the scarring 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 · Dcited before2025-07-22 · 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 observations, interviews and record reviews, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 of 1 medication rooms reviewed for medication storage. The facility failed to ensure the medication room was locked at 11:21 AM on 07/20/25 This failure could place residents in the facility at risk of drug diversion or misuse of medications leading to harm. The findings included:During an observation at 11:21 AM on 07/20/25, the medication room door was left slightly ajar, allowing this state surveyor to open the door and gain entrance without any key. No employees were in the medication room at that time. This state surveyor stayed by the entrance to the medication room until the ADM walked by at 11:50 AM and was informed the door was slightly ajar. In an interview with the ADM at 11:50 AM on 07/20/25, the ADM stated the medication room door was supposed to be closed and locked when no one was inside the room. The ADM stated 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
  • Potential for harm · D2025-05-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure the right to be free from abuse for one (Resident #1) of five residents reviewed for abuse. The facility failed to ensure Resident #1 was free from physical abuse on 01/13/25 when Resident #2 grabbed Resident #1 ' s head with both of his hands and hit Resident #1 ' s head against the wall several times then punched Resident #1 on the left side of his face with a closed fist. This failure could place residents at risk for physical, mental and psychosocial harm. Findings included: Record review of Resident #1's admission record on 05/14/25 reflected an [AGE] year-old male originally admitted to the facility on [DATE], with most recent admission on [DATE]. Resident #1's diagnoses included hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following cerebral infarction (stroke or brain injury) affecting left side, vascular dementia (problems with thought processes and memory caused by brain damage 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2024-12-18 · 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 observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 (Resident #1) of 3 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1 to address the risk for falls and the fall mat. This failure could place the residents at risk of not receiving appropriate interventions and care to meet their current needs. The findings included: Record review of Resident #1's face sheet dated 12/14/24 reflected a [AGE] year-old female with an original admission date of 11/15/24. Her diagnoses included: hydrocephalus (buildup of fluid in the brain ventricles), encephalopathy (brain dysfunction), muscle wasting and atrophy, dysphagia (difficulty swallowing), cognitive communication deficit, acquired…

    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 before2024-09-26 · 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

    Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments for 1 of 5 medication carts located at the nursing station observed for compliance. The facility failed to ensure one medication cart found at the nursing station for residents in the 500/600 hall was not left unlocked and unattended by RN A. This failure could place residents at risk of access and ingestion of non-narcotic medications. Findings were: During an observation on 9/24/2024, at 12:41 p.m., revealed one medication cart was unlocked at the nursing station without a supervised staff in view of the cart. The cart was left unlocked for less than 2 minutes until RN A returned to the cart, no one else was around the cart at the time, and all medications were non-narcotics. During an interview on 9/24/2024 at 12:41 p.m., RN A verbalized the unlocked cart was her cart. She verbalized she thought she locked it before walking to the kitchen. RN A stated it was proper process to lock the carts when the cart is not in view or when not being…

    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 before2024-06-26 · tag F0657 — failed to keep the care plan current — pattern
    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 observation, interview, and record review, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for three residents (Resident #14, Resident #30, and Resident #49) of 24 residents whose care plans were reviewed, in that: 1) Resident #14's comprehensive care plan was not revised after being prescribed Albuterol Sulfate Inhalation Nebulization Solution on 5/1/24 to reflect a respiratory plan of care. 2) Resident #30's comprehensive care plan was not revised after her quarterly safe smoking evaluations (assessments) changed. 3) Resident #49's comprehensive care plan failed to include he was a smoker. This failure could place residents at risk for inadequate care. The findings included: 1) Resident #14 Record review of Resident #14s face sheet dated 6/24/24 reflected a [AGE] year-old-female with an original admission date of 4/30/24. Diagnoses included cerebral infarction (stroke that occurs when a blood vessel 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Ecited before2024-06-26 · 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 for 1 of 1 kitchen reviewed for sanitation. 1. The facility failed to ensure juice dispenser nozzles were sanitary. 2. The facility failed to ensure equipment was clean and sanitized. 3. The facility failed to ensure the kitchen staff was following their policies. These failures could place residents at risk of foodborne illnesses. Findings included: Observation and initial tour of the kitchen on 06/24/24 beginning at 12:00 pm revealed 2 of 2 juice nozzle had a thick, sticky red substance that was congealed on and in the nozzles. Inside the nozzles, the same thick, sticky, congealed red substance was stuck to them. In an interview with the DA on 06/24/24 at 12:15 pm, she stated the juice nozzle were cleaned only at night. She stated the juice nozzle always looked like that, especially over the last four months. She stated there was a cleaning schedule the kitchen staff followed. In an interview with…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-26 · tag F0577 — isolated
    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 the results of the most recent survey of the facility in a place readily accessible to residents, family members, and legal representatives for ten (Resident # 3,28,37,42,48,50,55,57,64, and 169) of ten residents interviewed for resident rights. The facility failed to ensure the most recent survey results were readily accessible to residents, family members, and legal representatives. This failure could place residents, family members, and legal representatives at risk of not being able to fully exercise their right to be informed of the facility's survey results and citation history. Findings included: In an interview on 06/26/24 10:02 AM in a group meeting with ten residents (Resident # 3,28,37,42,48,50,55,57,64, and 169), all ten residents stated they were not aware of nor had they seen a previous survey binder. Observation on 06/26/24 at 11:00am revealed the survey results book was not located in the common areas of the facility nor was there a sign that indicated where the survey results book could…

    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 · Dcited before2024-06-26 · tag F0583 — failed to protect personal privacy — isolated
    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 the residents' right to privacy for 1 of 9 residents (Resident #32) reviewed for privacy. The facility failed to ensure RN A provided privacy by closing Resident #32's door or privacy curtain during administration of a subcutaneous insulin injection into Resident #32's abdomen on 06/25/2024 at 10:59 AM. This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life. The findings included: Record review of Resident #32's face sheet dated 06/26/2024 reflected a [AGE] year-old male with an original admission date of 06/14/2018 and a readmission date of 10/05/2021. Pertinent diagnoses include Type 2 Diabetes Mellitus (chronic condition that occurs when the body does not produce enough insulin or cells do not respond to insulin properly), Generalized Anxiety Disorder (feelings of extreme worry or nervousness even when there is little or no reason 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-26 · 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 nursing staff failed to demonstrate competencies and skills sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care, for one resident (Resident #14) of 24 residents reviewed, in that: -The facility failed to revise orders for Resident #14's code status from full code to DNR after receiving a DNR form from Resident #14's family member on [DATE]. Resident #14 had both CPR and DNR reflected in their orders. This deficient practice could affect residents who require care and monitoring and place them at risk of not receiving the care and services to meet their needs. The findings included: Record review of Resident #14s face sheet dated [DATE] reflected a [AGE] year-old-female with an original admission date of [DATE]. Diagnoses included cerebral infarction (stroke that occurs when a blood vessel that supplies the blood to the brain is blocked), pneumonia (inflammatory condition of the lung(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 · D2024-06-26 · 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 a comprehensive infection prevention and control program that included employing proper signage on the doors of resident's rooms to prevent the transmission of communicable diseases and infections for 2 of 28 residents (Resident #51 and Resident #19) reviewed for infection control. 1. The facility failed to place a readily visible EBP sign on the door of Resident #51 who was actively on EBP which requires an individual to don gown and gloves when performing patient care on 06/24/2024 at 11:35 AM. 2. The facility failed to place a sign on Resident #19's room door who was being tested for C. Diff(clostridioides difficile- a type of bacteria that is contagious and causes diarrhea and inflammation of the colon and can be life threatening) on 06/24/24. PPE such as gown and gloves was required to prevent cross contamination when providing care for residents with C-Diff. This failure could place residents at risk of cross contamination,…

    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 before2024-05-10 · tag F0657 — failed to keep the care plan current — isolated
    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 ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments, person-centered care plan to reflect the current condition for 1 of 11 residents (Residents #2) reviewed for care plan revisions. The facility failed to ensure Resident #2's care plan was comprehensive and updated to reflect Resident #2's fall preventions. This failure could place residents at risk of not receiving appropriate interventions meet their current needs. The findings include: Record review of Resident #2's admission records revealed an [AGE] year-old-female with an admission date of 07/28/22 and re-admission on [DATE]. Diagnoses included left femur (thigh)/hip fracture, heart failure, diabetes, osteoarthritis (severe bone degeneration), protein-calorie malnutrition, and muscle wasting. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS of 6…

    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 · D2024-05-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    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 observation, interview and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 resident (Resident #1) of 8 residents reviewed for quality of care. The facility failed to follow the physicians order on 08/16/2022 in accordance with the care plan for Resident #1's Wanderguard bracelet (device designed to prevent elderly individuals with dementia from wandering outside a perimeter) to be placed on her right arm. The Wanderguard bracelet was instead placed around her right ankle. This failure could place residents requiring supervision who had a Wanderguard at risk for injury and accidents. The findings included: Record review of Resident #1's face sheet dated 05/08/2024 reflected an [AGE] year-old female with an original admission date of 01/19/2022. Pertinent diagnoses includes dementia (mental decline that affects the quality of daily living) with exit seeking…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-04-06 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 5 of 5 staff (Dietary staff A, B, C, D and E) and 1 of 1 kitchen, in that: 1) Dietary staff failed to store, serve or process foods in a manner to prevent contamination, 2) Dietary staff failed to handle food contact equipment in a manner to prevent contamination, 3) Dietary staff failed to ensure food contact surfaces were clean, 4) Dietary staff failed to perform sanitary handwashing between the handling of soiled and clean food equipment during dishwashing, 5) Dietary staff failed to use good hygienic practices, including incorrect handwashing techniques, 6) TCS/PHF foods were not maintained at 41 degrees F and below or 135 degrees F or above 7) The dial probe thermometers were not accurate 8) Wiping cloth quaternary sanitizer solutions were not at required levels and was not tested correctly 9) Food contact equipment storage areas were not maintained in a clean and sanitary manner 10) Dietary…

    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 · E2023-04-06 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 all residents had the right to formulate an advance directive for 6 of 22 residents (Residents #3, #30, #31, #35, #57 and #59) reviewed for advanced directives. Resident #3, #30, #31, #35, #57 and #59 were incorrectly filled out or missing required information. Residents #3, #30, #31, #35, #57, and #59 were listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. This failure could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included : Resident #3 Record review of Resident #3's dated [DATE] face sheet revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include covid-19, dementia, type 2 diabetes mellitus and obesity. Record review of Resident #3's physician's order summary dated [DATE] revealed an order ADC: Do Not Resuscitate - DNR 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-06 · 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 record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for13 of 22 residents (Residents #4, #12, #19, #20, #28, #30, #31, #33, #42, #45, #47, #56, and #59) reviewed for care plans as follows: Resident #4 did not have a care plan for behavior. Resident #12 did not have a care plan for vision and dehydration. Resident #19 did not have a care plan for communication, falls and dehydration. Resident #20 did not have a care plan for vision, communication and dental care. Resident #28 did not have a care plan for dehydration. Resident #30 did not have a care plan for mood and dental care. Resident #31 did not have a care plan for vision and communication. Resident #33 did not have a care plan for vision and pain. Resident #42 did not have a care plan for dehydration. Resident #45 did not have a care plan for vision, communication, activities of daily living, falls and dehydration. Resident #47 did not have…

    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 before2023-04-06 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, in that: One of one medication rooms was unlocked and unattended on four different occasions. LVN A left medications on storage cart unlocked and unattended in the hallway. These failures could result in the theft or misuse of medications. The findings include: 4/4/23 at 8:39 AM an observation was made of the hall 300 medication room entrance door. The door was ajar unlocked, and the room was unattended. 4/4/23 at 12:24 PM, an observation was made of the hall 300 medication room unlocked and unattended. 4/4/23 at 1:59 PM an observation was made of the hall 300 medication room, and the door was a jar, unlocked, and the room was unattended. 4/4/23 at 2:07 PM an observation was made of the hall 300 medication room, and the door was still ajar and the room was unattended. During an observation of medication pass on 4/5/23, LVN A left medications on top 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
  • Potential for harm · E2023-04-06 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 3 of 3 meals. 1) The facility failed to provide food that was palatable for 3 of 3 meal observed (4/04/23, lunch and dinner) and 4/05/23, lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings include: During the Resident Council Meeting on 4/05/23 at 10:00 AM, residents were confidentially interviewed about food palatability. Two of 6 residents voiced concerns about the temperature and flavor of the food served. One resident stated the food was always cold. The resident further stated he ate in his room and the tortillas were not cooked well and were soggy. Another resident stated the food was always cold; all meals were cold. - The following observations were made, and interviews conducted during a kitchen tour on 4/4/23 that began at 11:50 AM and concluded at 12:58 PM: On 4/4/23…

    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 · E2023-04-06 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs, for 3 of 3 meals observed for 5 of 5 residents with orders for pureed diets (Residents #11, 18, 37, 43 and 49); in that: 1) The facility failed to provide food that was in a form to meet resident needs during 3 of 3 meal observed (4/04/23, lunch and dinner) and 4/05/23, lunch) for 5 of 5 residents with orders for pureed diets (Residents #11, 18, 37, 43 and 49). These failures could place residents at risk of decreased food intake and choking. The findings include: - The following observations were made, and interviews conducted during a kitchen tour on 4/4/23 that began at 11:50 AM and concluded at 12:58 PM: On 4/4/23 at 12:18 PM temperatures were taken on the service line by Dietary Staff B. Purée meat/Carne Guisada was 135°F and had a coarse/grainy appearance Puréed potato tots were 124°F and had a coarse/ grainy appearance…

    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 · D2023-04-06 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 review, the facility failed to ensure each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 2 of 22 residents (Residents #19 and #62) reviewed for self-determination in that: The facility failed to ensure Resident #19 received daily showers as requested. The facility failed to ensure Resident #62 receive daily showers as requested. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that are important in their life and decrease their quality of life. The findings were : Resident #19: Record review of Resident #19's face sheet, dated 04/04/23, revealed a [AGE] year-old male admitted to facility 04/03/23 with diagnoses that included type II diabetes and paraplegia. Record review of Resident #19's Comprehensive MDS dated [DATE] revealed a BIMS score of 14 indicating he is cognitively intact . Section G0120. Bathing…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-06 · 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, based on a resident's comprehensive assessment, ensure that a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 2 of 5 residents with gastrostomy tubes (Residents #53 and #57); in that: 1) (Resident #53 and #57 had G-tube feedings that were not administered according to physician's orders, and 2) G-tube flushing equipment (flushing syringes) was not stored in a sanitary manner after use (Residents #53 and #57). These problems could result in the residents on feeding tubes experiencing feeding tube associated complications which could include aspiration pneumonia, discomfort, and inadequate nutrition. The findings include: Resident #53: Record review of the Order Summary…

    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 · D2023-04-06 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, in that two of seven residents (Resident #4 and Resident #58) continued to receive psychotropic medications PRN for more than 14 days without a physician addressing the continued use of the medication: - Resident #4 continued to have a PRN order for Lorazepam(anti-anxiety) 0.5mg after 14 days without an evaluation by the physician for continued treatment. - Resident #58 continued to have a PRN order for Lorazepam(anti-anxiety) 0.5mg after 14 days without an evaluation by the physician for continued treatment. This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions. The findings include: Resident #4 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.

    Pharmacy Service 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

$8,021 in federal fines across 1 penalty.

  • $8,021 — penalty dated 2024-05-10

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 WELLSENTIAL HEALTH — 67 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 52.7+1.3 vs chain
Health inspection 4 of 52.9+1.1 vs chain
Staffing 3 of 51.6+1.4 vs chain
Quality measures 4 of 54.2-0.2 vs chain
The other 66 homes this chain runs (chain average 2.7★, per CMS)
1 of 5Bastrop Lost Pines Nursing and Rehabilitation CentBastrop, TX 1 of 5Briarcliff Nursing and Rehabilitation CenterMcAllen, TX 1 of 5Brownsville Nursing and Rehabilitation CenterBrownsville, TX 1 of 5Fort Worth Transitional Care CenterFort Worth, TX 1 of 5Hidalgo Nursing and Rehabilitation CenterEdinburg, TX 1 of 5Houston Heights Nursing and Rehabilitation CenterHouston, TX 1 of 5Jefferson Nursing And Rehabilitation CenterBeaumont, TX 1 of 5Laredo West Nursing and Rehabilitation CenterLaredo, TX 1 of 5Lavaca Bay Nursing And Rehabilitation CenterPort Lavaca, TX 1 of 5Longview Hill Nursing and Rehabilitation CenterLongview, TX 1 of 5Spindletop Hill Nursing And Rehabilitation CenterBeaumont, TX 1 of 5Town and Country Nursing and Rehabilitation CenterBoerne, TX 1 of 5Wharton Nursing and Rehabilitation CenterWharton, TX 1 of 5Windsor Nursing And Rehabilitation Center Of RaymoRaymondville, TX 2 of 5Brenham Nursing and Rehabilitation CenterBrenham, TX 2 of 5Cityview Nursing and Rehabilitation CenterFort Worth, TX 2 of 5Corpus Christi Nursing And Rehabilitation CenterCorpus Christi, TX 2 of 5Edinburg Nursing and Rehabilitation CenterEdinburg, TX 2 of 5Elgin Nursing And Rehabilitation CenterElgin, TX 2 of 5Guadalupe Valley Nursing And Rehabilitation CenterSeguin, TX 2 of 5Hallettsville Nursing And Rehabilitation CenterHallettsville, TX 2 of 5Heritage Park Rehabilitation And Skilled Nursing CAustin, TX 2 of 5Live Oak Nursing and Rehabilitation CenterGeorge West, TX 2 of 5Maverick Nursing and Rehabilitation CenterEagle Pass, TX 2 of 5Memorial City Nursing and Rehabilitation CenterHouston, TX 2 of 5Robstown Nursing And Rehabilitation CenterRobstown, TX 2 of 5Southpark Meadows Nursing and Rehabilitation CenteAustin, TX 2 of 5Windsor AtriumHarlingen, TX 2 of 5Windsor Nursing And Rehabilitation Center Of SeguiSeguin, TX 2 of 5Windsor Nursing And Rehabilitation Center Of WeslaWeslaco, TX 2 of 5Windsor Nursing and Rehabilitation Center of AliceAlice, TX 2 of 5Windsor Nursing and Rehabilitation Center of BastrBastrop, TX 2 of 5Windsor Nursing and Rehabilitation Center of MorgaCorpus Christi, TX 2 of 5Yoakum Nursing And Rehabilitation CenterYoakum, TX 3 of 5Harlingen Nursing and Rehabilitation CenterHarlingen, TX 3 of 5Magnolia Crossing Nursing and Rehabilitation CenteHouston, TX 3 of 5Port Lavaca Nursing And Rehabilitation CenterPort Lavaca, TX 3 of 5The Woodlands Nursing And Rehabilitation CenterThe Woodlands, TX 3 of 5Val Verde Nursing And Rehabilitation CenterDel Rio, TX 3 of 5Windsor Mission OaksSan Antonio, TX

Showing 40 of 66; 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
TAYS, ANTONIOIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 10/01/2022
APOLINAR, ADAMIndividualCORPORATE OFFICERsince 07/23/2015
CONTRERAS, TERRIIndividualCORPORATE OFFICERsince 04/29/2019
ELLIOTT, BENJAMINIndividualCORPORATE OFFICERsince 01/13/2016
FAGLIE, KELLYIndividualCORPORATE OFFICERsince 03/31/2017
GAITONDE, GAJANANIndividualCORPORATE OFFICERsince 02/28/2006
GONZALES, HECTORIndividualCORPORATE OFFICERsince 03/27/2001
GUTIERREZ, MONICAIndividualCORPORATE OFFICERsince 01/13/2016
KESSLER, WILLIAMIndividualCORPORATE OFFICERsince 02/27/1973
ZAMORA, RAULIndividualCORPORATE OFFICERsince 12/30/1980
LEDET, DANRICKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2022
CSV RHEA MANAGEMENT HOLDCO, LLCOrganizationADP OF THE SNFsince 10/01/2022
DWD TX HOLDINGS LLCOrganizationADP OF THE SNFsince 10/01/2022
JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INCOrganizationADP OF THE SNFsince 10/01/2022
REG LEASED OPCO LLCOrganizationADP OF THE SNFsince 10/01/2022
REG OPERATOR HOLDCO LLCOrganizationADP OF THE SNFsince 10/01/2022
REGENCY IHS CLINICAL CONSULTING, LLCOrganizationADP OF THE SNFsince 10/01/2022
REGENCY IHS OF SOUTH LAREDO LLCOrganizationADP OF THE SNFsince 10/01/2022
REGENCY IHS REHAB LLCOrganizationADP OF THE SNFsince 01/01/2025
REGENCY INTEGRATED HEALTH SERVICES LLCOrganizationADP OF THE SNFsince 04/17/2025
REGENCY TEXAS HOLDINGS LLCOrganizationADP OF THE SNFsince 10/01/2022
UVALDE COUNTY HOSPITAL AUTHORITYOrganizationADP OF THE SNFsince 04/17/2025
CASAS, CARLOSIndividualADP OF THE SNFsince 01/01/2026
LEAL, OLIVIAIndividualADP OF THE SNFsince 10/01/2022

CMS files one row per role, so the 26 rows in the source record cover these 24 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.

11 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.

$5.8M
Net patient revenuemost recent cost report
-9.7%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 86%Medicare 8%Other / private 6%

About 86% 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 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

$268per resident / day
operating cost
$8,142per month
≈ monthly operating cost
$244per 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 675396. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-22, 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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