Lynwood Nursing and Rehabilitation
803 S Alamo, Levelland, TX 79336 · For profit - Corporation · 120 certified beds · (806) 894-2806 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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 (31) — 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 2025-09-03)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 24.7% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.7% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.5% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 3.1% | 2.4% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.9% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 18.9% | 14.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 19.1% | 18.0% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.4% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 9.6% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 88.0% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.44 | 2.17 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.00 | 2.06 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.68 therapist hours per resident per day in 2026Q1 — more than 91% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.8%CMS range 7.2–18.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not 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 discharge | not 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 discharge | not 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 identified | not 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 setting | not 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 discharge | not 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 stay | not 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 worsened | not 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 hospitalization | not 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 SNFs | 1.38 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 55.8 residents a day — about 46% occupied, or roughly 64 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 2.80 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.75 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 2.49 hrs/resident/day on weekends vs 2.93 on weekdays — 15% thinner on weekends. RN hours go from 0.48 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-09-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure adequate supervision of Resident #1 who was newly admitted to the facility on [DATE] and was exhibiting signs of confusion and exit-seeking behavior. Resident #1 then eloped from the facility approximately 27 (twenty-seven) hours later on 07/20/25 between 7:45 PM and 8:00 PM. Staff were unaware of Resident #1's elopement when the facility was notified by a citizen of the community via telephone on 07/20/25 at approximately 8:15 PM that the resident had wandered to a nearby apartment complex and appeared confused. The noncompliance was identified as PNC. The IJ began on 07/20/25 and ended on 07/21/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of harm, serious injury or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-13 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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
Based on interviews and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 10 of 19 residents in that: The facility failed to ensure staff were not on their personal cell phones while providing care, which included peri-care to residents. This could place residents at risk for diminished quality of life and loss of dignity and self-worth. Findings include: During an interview with confidential residents on January 12, 2026, at 10:00am ten confidential residents stated the use of cell phones by CNAs while performing care made them feel ignored, not a priority, embarrassed, concerned the CNA could make a mistake due to distraction by the cell phone conversation, and, most of all, their privacy was violated. During an interview on January 12, 2026, at 10:00am ten confidential residents stated the use of cell phones…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-13 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (1/11/26 lunch). This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.The Findings included: During confidential individual interviews on an undisclosed date and time, 10 of 10 residents voiced concerns related to food palatability. They stated, the rolls were raw, and they could not chew them. They further stated, the vegetables are unrecognizable due to being cooked too long. The following dining observations were made during lunch meal on 1/11/26 that began at 12:22 a.m. and concluded at 1:03 p.m. Observation of the puree foods served for 6 of 6 residents on puree diet revealed, puree seasoned chicken thighs and pureed mac-n-cheese had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's 1 of 1 kitchen reviewed for food safety. 1) The facility failed to ensure food items in the refrigerators (2) and freezers (2), were labeled and stored in accordance with the professional standards for food service. 2) The facility failed to ensure the iced tea machine's outer surface was free from dirt and stains. 3) The facility failed to ensure the refrigerators (2) and freezers (2) outer handle surface were free from greasy stains. These failures could place residents at risk for food-borne illness and cross contamination.These failures could place residents at risk for food-borne illness and cross contamination. The findings included: During kitchen tour observations on 1/11/26 that began at 10:08 a.m. and concluded at 10:51 a.m., revealed the following: Iced tea machine, located inside the kitchen's beverage station, had dirt and stains. Reach-in refrigerator #1 revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-13 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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 the menu was followed for the lunch meal on 1/11/26 for 1 of 1 meal (the lunch service on 1/11/26) reviewed for nutritional adequacy. The facility failed to follow the lunch menu for 1/11/2026 and did not inform the residents that a substitute would be served. This failure could place residents at risk of not receiving adequate nutritive food value needed to promote/maintain health. The Findings included: Record review of the weekly menu for week five's Sunday lunch revealed braised beef tips with gravy, steamed rice, roasted brussels sprouts, dinner rolls and frosted cake. During a dining observation on 1/11/2026 from 12:22 p.m. to 12:51 p.m., a handwritten message written on a whiteboard next to the kitchen entrance said, Lunch: seasoned chicken thighs, chicken gravy, mac and cheese, dinner roll, frosted cake. Only two food items, dinner rolls and frosted cake, were observed to be included in the lunch meal served. During a confidential meeting on an undisclosed date and time, ten of ten…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #27) reviewed for wound care.RN A failed to change her gloves during wound care for Resident #27.This failure could place residents at risk for cross contamination and infection.Findings included:Record review of Resident #27's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #27 had a medical history of pulmonary embolism (a sudden blockage in a lung artery), respiratory failure, and heart failure.Record review of Resident #27's MDS, dated [DATE], Section C- Cognitive Patterns, revealed a BIMS score of 13 which indicated Resident #27 was cognitively intact.Record review of Resident #27's care plan, dated 12/10/2025, revealed (Resident #27) refuses or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-08 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 (Resident # 1) residents reviewed for pharmaceutical services. The facility failed to ensure MA A completed the medication administration for Resident #1 according to standard of practice when she placed the medications in Resident #1's mouth during the breakfast meal and left prior to observing that Resident #1 had swallowed the medications. Resident #1's medications were found in a cup beside the resident's breakfast tray by the resident's family member who assisted Resident #1 to finish taking the medications. This failure could place residents at risk of not receiving the full medication dosage or intended therapeutic benefit of ordered medications.Record review of Resident #1's undated face sheet revealed an [AGE] year-old female admitted 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.
- Potential for harm · Dcited before2025-09-03 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 observations, interviews, and record review, the facility failed to treat residents with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 8 residents (Resident #2 and #3) reviewed for respect. CNA D failed to treat residents with respect and dignity when she told Resident #2 and Resident #3, she did not have to take them out to smoke, on an unknown date in July 2025. These failures could place the residents at risk of feeling disrespected.Findings included: Record review of Resident #2's undated face sheet revealed a [AGE] year-old male admitted on [DATE]. Resident #2 had a medical history of COPD (a group of lung diseases that cause airflow obstruction and breathing difficulties), alcohol induce dementia (a type of alcohol-related brain damage), and muscle weakness. Record review of Resident #2's quarterly MDS dated [DATE], Section C-Cognitive Patterns revealed a BIMS score of 06, which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-05 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 interviews and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promoted the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 of 7 (Resident #1) residents reviewed for resident rights. CNA B failed to allow Resident #1 to call her Family Member when Resident #1 requested to make that call at approximately 2:30 AM on 01/24/25. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth. Findings included: Record review of Resident #1's undated face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had a medical history of type 2 Diabetes Mellitus (inability of the body to use insulin properly), altered mental status (change in a person's awareness and alertness), major…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 interview and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 7 residents (Resident #1) reviewed for hygiene, in that. 1. The facility failed to provide incontinence care on three separate opportunities for Resident #1 on 1/26/2025. These failures could place residents at risk for skin breakdown and infections. Findings include: Record Review of Resident #1's undated face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had a medical history of nondisplaced fracture of third cervical vertebra (fracture of bones in the neck), anxiety disorder, major depressive disorder, restlessness and agitation, type 2 diabetes, hypertension (high blood pressure) and chronic pain. Record Review of Resident #1's MDS dated [DATE] revealed Section C- Cognitive patterns a BIMS score of 13 which indicated Resident #1 was cognitively…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-10-29 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 10 (4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024) of 91 days reviewed for RN coverage. The facility failed to maintain RN coverage of eight hours a day for 10 days 4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024). This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care. Findings included: Record review of the CMS report PBJ Staffing Data Report dated 10/23/24 reflected no RN hours for 4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024. Record review of the facility''s employee survey roster undated reflected there were seven RNs employed at the facility. Record review of Schedule Sheet dated April 2024 reflected RN A was scheduled to work on (4/13, 4/14, and 4/28/2024). Record review of Schedule Sheet dated May 2024 reflected RN A was scheduled to work on (5/18, 5/19, 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.
Show the remaining 20 citations
- Potential for harm · E2024-10-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice for 2 (Residents #40 and #114) of 2 residents reviewed for respiratory care. 1. The facility failed to ensure that Resident #40 and Resident #114's oxygen tubing was replaced every week on Sunday, according to physician's orders. These failures could place residents at risk for respiratory compromise and infection. Findings included: Resident #40 Record review of Resident #40's clinical record reflected a face sheet, dated 10/28/24, which indicated the resident was an [AGE] year-old female admitted to the facility on [DATE]. Resident #40's diagnoses included chronic obstructive pulmonary disease (lung disease) and dementia (memory loss). Record review of Resident #40's annual MDS dated [DATE] revealed a BIMS score of 04, indicating the resident had severe cognitive impairment. Section O - Special Treatments,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-29 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that its medication error rates are not 5 percent (%) or greater. The facility had a medication error rate of 20% based on 6 out of 30 opportunities, which involved 2 of 4 residents (Residents #58 and #55) reviewed for medication administration, in that: 1. The facility failed to ensure Resident #55 had Xifaxa n (helps prevent a brain condition that can occur with severe liver disease )550mg, available for administration, resulting in a missed dose. 2. Med Aide C failed to verify the dosage and amount on Resident #55's Lactulos e (treats constipation) resulting in Resident #55 being underdosed. 3. Med Aide C failed to verify the dosage for Resident #58's Magnesium 200mg (treats low magnesium levels), and thiamin B1 (treats low thiamine) 50mg resulting in an incorrect dose given. 4. Med Aid C failed to verify physician order for Resident #58's Multivitamin resulting in the incorrect multivitamin given. 5. Med Aid C administered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-29 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1. The facility failed to store and date foods stored in the refrigerator. 2. The facility failed to store pans upside down on shelfs. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 10/27/24 at 09:45 AM, during initial observation of the kitchen: Observed the following: Inside the Refrigerator: Three trays with individual deserts in bowl uncovered and no date. -A bowl of puree food covered with plastic wrap with no date. -Two half sandwiches in plastic wrap with no date. Shelf: -One large pot laying on side on bottom shelf in pantry. -Three small pans stored right side up on shelf in kitchen. During an interview on 10/29/24 at 10:35 AM with the ADM, she stated all food should be stored covered and dated. She stated pots/pans should be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-29 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 2 residents (Residents #4 and #38) and 2 of 2 (LVN A and LVN B) staff reviewed for infection control. LVN A failed to wash hands between glove changes during wound care for Resident #38. LVN B failed to wash or sanitize hands after reaching in his pocket and prior to starting wound care. These failures could place residents at risk for spread of infection and cross contamination. Findings include: Resident #4 Record review of Resident #4's clinical record reflected a face sheet, dated 10/29/24, which indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #4's diagnoses included dementia (loss of cognitive functioning, thinking, remembering, and reasoning) unspecified open wound right foot (break in the skin exposing underlying…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-29 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 7 of 15 confidential residents. The facility failed to ensure 7 confidential residents were provided, through postings in prominent locations, the Grievance Procedure, was provided access to the Grievance form, was provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews and record review during Resident Council on, 10/28/2024 at 10:00 a.m., 7 confidential residents, stated they did not know the grievance process, they did not know where to obtain or submit a grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-29 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored properly in the treatment cart for 1 of 1 treatment carts observed for drug storage. The facility failed to ensure 2 bottles of wound cleaners was not left on top of the treatment cart unattended. This failure could place residents at risk of access and ingestion of non-narcotic medications. The findings were: During an observation on 10/28/24 at 03:45 PM, LVN A prepared wound care supplies on the treatment cart outside of resident's room. LVN A gathered supplies leaving 2 bottles of wound cleaners on top of treatment cart and entered resident's room. LVN A closed the door to resident's room. During an observation on 10/28/24 at 03:50 PM, the wound cleanser bottle on top of treatment care reflected the following warnings: Keep out of reach of children. If swallowed seek medical attention or call a Poison Control Center. During an interview on 10/28/24 at 03:52 PM, LVN A stated she should not have left the wound cleaners…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-16 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 6 residents (Resident #1 and Resident #2) reviewed for care plans. The facility failed to have a care plan in place to accurately address Resident #1's wound care. The facility failed to have a care plan in place to accurately address Resident #2's oxygen use. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Resident #1 Record review of Resident #1's Face Sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included Stroke (damage to brain from interruption of blood supply), Traumatic Brain Dysfunction (a disruption in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-06 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 7 residents (Resident #1) reviewed for MDS assessment accuracy. Resident #1's quarterly MDS assessment dated [DATE] was coded incorrectly for wandering reflecting that she did not wander when she had a consistent presence of the behavior (wandering). Resident #1's quarterly Significant Change assessment dated [DATE] was coded incorrectly for wandering reflecting that she did not wander when she had a consistent presence of the behavior (wandering). Resident #1's quarterly and comprehensive assessment did not reflect the behavior for wandering even though staff (ADM, DON, LVN A, LVN B, The Activity Director, CNA C, CNA D, the MDS Coordinator and CNA E) had witnessed her wandering since her admission [DATE]) into other resident room and specifically Resident #2's room. This failure could place residents at risk of not receiving care and services to meet their needs.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-06 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 1 of 7 residents (Resident #1) reviewed for care plans as follows: 1. Resident #1 did not have a care plan for her ongoing behavior for wandering that had occurred since her admission on [DATE]. These failures could place residents at risk of not receiving the care required to meet their Individualized needs. Findings include: Review of Resident #1's face sheet (undated) indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a diagnoses of dementia with agitation (loss of cognitive functioning), generalized anxiety disorder (feelings of worry, tension and fear), and intermittent explosive disorder (repeated , sudden bouts of impulsive of physical or verbal outburst). Resident #1 resided on Hall 100. Review of Resident #1's quarterly MDS dated [DATE] revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 dietary services, in that: 1)The facility failed to ensure foods were processed and pureed under sanitary conditions, 2) The facility failed to ensure Dietary staff ensured food and non-food contact surfaces were clean, and 3) The facility failed to ensure foods were stored in a manner to prevent contamination, These failures could place residents at risk for food contamination and foodborne illness. The findings included: - The following observations were made during a kitchen tour on 9/18/23 that began at 9:44 AM and concluded at 10:12 AM: 4 of 4 cutting boards had black smears and stored in a rack as clean. There was an unshielded light bulb in the vegetable refrigerator. - The following observations were made, and interviews conducted during a kitchen tour on 9/18/23 that began at 10:53 AM and concluded at 12:24 PM: The underside of the stove upper shelf had a heavy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-20 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 4 of 5 common baths (100/200, 300, 500 and 600), reviewed for environment, in that: The facility failed to ensure resident use common areas were clean, safe and did not need repair. These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being. The findings include: On 9/18/23 at 4:27 PM an observation was made of the 100/200 bath. The shower chair in the room had a heavy buildup of residue and dirt on the mesh back. There were three dried brown mounds on the floor in the shower stall. The mounds were approximately an inch in diameter. On 9/18/23 at 4:32 PM an observation was made of the hall 300 bath. The shower chair had a buildup of residue on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 that the resident environment remained as free of accident hazards as was possible in 4 of 5 Baths (100/200, 300, 400 and 500) and 1 of 22 resident rooms (room [ROOM NUMBER]) reviewed, in that: The facility failed to maintain resident use hot water at safe and comfortable temperatures. Resident-use hot water was not reliably controlled. Hot water temperatures ranged from 113.5 to 117.9 F, and The facility failed to ensure chemicals were stored in a manner to prevent contamination of resident use items. This failure could place residents at risk for injuries related to chemical contact and could place residents at risk for sustaining scalding injuries when using resident-use/resident accessible hot water. The findings include: Observation on 9/18/23 at 2:09 PM in room [ROOM NUMBER] revealed the hot water at the room's hand sink was 117.5°F. Observation on 9/18/23 at 2:15 PM revealed the hot water in room [ROOM NUMBER] tested at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-20 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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, and at a safe and appetizing temperature for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical soft and pureed) at 1 of 1 meal observed (9/20/23 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews, 4 of 14 residents voiced concerns related to the palatability of the foods served. On 9/18/23 At 10:44 AM a resident stated the food was too salty and too cold. On 9/18/23 at 1:30 PM another Resident stated the food was not good and had no seasoning. On 9/19/23 at 9:11 AM one other Resident stated the food is horrible and bland. On 9/19/23 at 9:30 AM yet another Resident stated the food had no flavor. On 9/20/23 at 11:37 AM, an interview was conducted with the Dietary Manager and she 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.
- Potential for harm · Dcited before2023-09-20 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 of 20 (Resident #19) residents in that: CNA A failed to provide Resident #19 privacy during incontinent care. This could place residents at risk for diminished quality of life and loss of dignity and self-worth. The findings included: A record review of Resident #19's face sheet, dated 09/20/23, revealed a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses to include COPD (lung disease), muscle weakness, major depressive disorder (mental illness), heart disease, dementia (cognitive loss), and hypertension (high blood pressure). Record review of Resident #19's Comprehensive Minimum Data Set 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.
- Potential for harm · D2023-09-20 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 2 of 18 residents (Residents #35 and #45) reviewed for PASRR screening, in that: Residents #35 and #45 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of mental illness. These failures could place residents with an inaccurate PASRR Level 1 Evaluation at risk for not receiving care and services to meet their needs. The findings were: Resident #35: Record review of Resident #35's electronic face sheet revealed a [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under Diagnoses Information, Schizoaffective Disorder, Bipolar type. Record review of Resident #35's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of Schizoaffective Disorder, Bipolar type. Additionally, under Section C Cognitive Patterns,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 Residents (Resident #24 and #32) reviewed for incontinent care. 1. CNA B failed to properly clean labia (middle of vaginal area) and wash hands between glove changes while providing incontinent care to Resident #24. 2. CNA C failed to change gloves and wash hands when going from dirty to clean while providing incontinent care to Resident #32. This failure had the potential to affect residents by placing them at an increased risk of exposure to communicable diseases and infections. Findings include: Resident #24 Record review of face sheet for Resident #24, dated 09/20/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: dementia (cognitive loss), atrial fibrillation (irregular…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-20 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly in 1 of 4 dumpsters (#1) and 2 of 2 grease barrels, in that: The facility failed to maintain the dumpster/refuse disposal containers in a manner that effectively prevented the harborage and attraction of pest. These failures could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility. The findings include: On 9/18/23 at 10:06 AM an observation was made of the dumpster area. The exterior of two of two grease barrels revealed that they had a heavy buildup of grease and food debris. The ground surrounding the two barrels had an accumulation of grease spillage on the dirt. It was approximately a 1' to 2' perimeter all the way around the two barrels that had the hardened grease and food debris buildup on the ground. The barrels were located away from concrete slab. On 9/19/23 at 8:29 AM an observation of the dumpster area. One of 4 had one of two lids open (#1). The grease barrels, 2 of 2, were heavily coated 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.
- Potential for harm · Dcited before2023-09-20 · tag F0851 — isolatedElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specification established by CMS for 1 of 1 facility reviewed for administration (Fiscal year 2023 for the third quarter April 1, 2023, to June 30, 2023). The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for the third quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met. Findings included: Record review of the CMS 672 form dated 9/18/23 and signed by the DON that was provided by the Administrator indicated a total of 64 residents in the facility. Record review of the CMS PBJ Staffing Data Report (payroll based staffing), CASPER Report (Certification and Survey Provider Enhanced Report)1705 D FY Quarter 3 2023 (April 1- June 30), dated 09/14/2023, indicated the following entry: Failed to Submit…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of diseases for 2 of 3 (Residents #24 and #32) and 1 of 1 (CNA B) staff reviewed for infection control. 1. CNA B failed to properly serve residents meals by touching the rim of glasses and bowls. 2. CNA B failed to perform hand hygiene between glove changes when providing incontinent care for Resident #24. 3. CNA C failed to perform hand hygiene between glove changes when providing incontinent care for Resident #32. These failures could place residents at risk for spread of infection and cross contamination. Findings include: Observation on 09/18/23 at 12:10 PM CNA B was observed serving residents meal by picking the glass and bowl up off tray by the rim with bare hands. Observation on 09/19/23 at 05:20 PM CNA B was observed serving residents meal by picking the glass and bowl up off 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.
- No harm found · B2023-09-20 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of 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 interview and record review, the facility failed to ensure MDS automated data processing requirements were followed regarding encoding data and transmitting data for a discharge of 1 of 1 resident reviewed (Resident #58), in that: 1)The facility failed to submit a discharge MDS for Resident #58 who discharged from the facility on 5/19/23. These failures could lead to inaccuracies in resident MDS records. The findings include: Record review of admission MDS dated [DATE] and Progress Notes dated 3/23/23, for male Resident #58 revealed that he was admitted to the facility on [DATE]. The resident had active diagnoses of CVA (stroke), hypertension (high blood pressure), diabetes mellitus (blood sugar imbalance), hyperlipidemia (elevated cholesterol), hemiplegia (one side weakness). The resident had a BIMS score of 14 indicating the resident was cognitively intact. Record review of the ASEQ Survey documentation system revealed that Resident #58 had a MDS Record over 120 days old. Record review of the Progress…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,281 in federal fines across 1 penalty.
- $8,281 — penalty dated 2025-09-03
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 SLP OPERATIONS — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.1 | +1.9 vs chain |
| Health inspection | 3 of 5 | 2.3 | +0.7 vs chain |
| Staffing | 2 of 5 | 1.1 | +0.9 vs chain |
| Quality measures | 5 of 5 | 4.0 | +1.0 vs chain |
The other 6 homes this chain runs (chain average 2.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SLP OMEGA OPERATIONS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 08/01/2020 |
| SENIOR LIVING PROPERTIES LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/01/2020 |
| SLP MANAGEMENT HOLDINGS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/01/2020 |
| SLP OPERATIONS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/01/2020 |
| BOSWELL, DARREN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/01/2020 |
| EDEN, JAMES | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/01/2020 |
| WHITWORTH, GARY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/01/2020 |
| TEXAS FIFTEEN PROPERTY LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 08/01/2020 |
| LEONARD, JOSHUA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2024 |
| SKINNER, DEREK | Individual | ADP OF THE SNF | — | since 02/01/2021 |
| WHITESIDES, JESSICA | Individual | ADP OF THE SNF | — | since 03/01/2023 |
CMS files one row per role, so the 13 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
5 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.
About 74% 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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 455871. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-13, 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.