Vista Ridge Nursing & Rehabilitation Center
700 E Vista Ridge Mall Dr, Lewisville, TX 75067 · Government - Hospital district · 132 certified beds · (972) 906-9789 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- 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 $10,348 in federal fines (most recent 2025-04-02)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (62%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| 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
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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 |
| Short-stay residentsrehab / post-hospital | 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.
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 | 7.5% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.2% | 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 | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 2.1% | 2.4% | 6.5% | better 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 | 2.3% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 6.6% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.9% | 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 | 3.9% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 8.3% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.9% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.1% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.8% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.8% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.93 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.93 | 2.06 | 1.80 | 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.
51.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 102 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 82.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 34 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.95 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 51.8%CMS range 41.0–61.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 7.6–14.9 | 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 | 82.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 82.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 47.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 3.8–10.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.31 | 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 132 beds and averages 82.1 residents a day — about 62% occupied, or roughly 50 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.05 hrs/resident/day on weekends vs 3.62 on weekdays — 16% thinner on weekends. RN hours go from 0.89 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 62% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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 · K2025-04-02 · 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 each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #1) of five residents reviewed supervision. The facility failed to ensure Resident #1 (who was ordered a pureed diet and was a known aspiration risk) was provided with adequate supervision during the lunch meal on 04/01/25. Resident #1 was sat at a table with another resident who offered her a cookie, which Resident #1 accepted and ate, which led to her coughing several times before finishing the cookie. Five staff were in the dining room but no one was supervising the resident at the time to ensure safety or noticed she was eating outside her modified diet texture. An IJ was identified on 04/01/25 at 4:55 PM. The IJ template was provided to the facility on [DATE] at 4:57 PM. While the IJ was removed on 04/02/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal…
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 · D2026-06-09 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 interview and record review, the facility failed to ensure the resident had the right to be free from abuse for one of seven residents (Resident #1) reviewed for abuse.The facility failed to ensure Resident #1 was free from verbal abuse by CNA A. This failure could place residents at risk for abuse or neglect that could lead to serious harm. Findings included: Record review of Resident #1's face sheet, dated 06/09/26, reflected a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dysarthria (a motor speech disorder caused by nervous system damage that weakens, paralyzes, or reduces coordination of the muscles used for speech) and anarthria (the complete loss of the ability to produce articulate speech due to severe neuromuscular damage), cognitive communication deficit (an underlying disruption in thinking like poor memory, attention, or executive functioning impairs a person's ability to effectively speak, listen, read, or write), muscle weakness,…
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 · D2026-04-09 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 implement written policies and procedures that prohibit and prevent abuse and neglect for 1 of 5 residents (Resident #5) reviewed for reporting according to the facility policy.The facility failed to follow the facility's policy to report allegation of abuse when Resident #5 made an outcry to the Psychologist regarding sexual abuse from her FM on 3/24/26.This failure could place residents in the facility at risk of abuse and lack of timely reporting of incidents.Record review of Resident #5's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, which meant she had moderate cognitive impairment. Resident #5 had unclear speech, sometimes made herself understood and usually understood others. Resident #5 needed substantial/maximal assistance for oral hygiene, toileting hygiene, showering, upper body dressing, and personal hygiene. Resident #5 needed substantial assistance to roll left and right and to sit to lying.Record review of Resident #5's Care…
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 · D2026-04-09 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to other officials (including the State Survey Agency where state law provided for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 out of 5 residents (Resident #5) reviewed for abuse or neglect.The facility failed to report an allegation of abuse to the State Survey Agency (HHSC) after they learned Resident #5 had made an allegation of sexual abuse against her FM on 3/24/26. These failures could place residents at risk of abuse, allegations of abuse not being reported immediately, and could result in physical and psychological harm. Record review of Resident #5's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted 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.
- Potential for harm · D2026-04-09 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report the results of all investigations to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident.The facility failed to submit a completed investigation regarding the allegation sexual abuse of Resident #5 by her FM to the State Survey Agency.This failure placed residents at risk of further abuse and a lack of oversight by the State Survey Agency.Record review of Resident #5's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosis included: Aphasia (a communication disorder resulting from damage to brain areas responsible for language) following Cerebral Infarction (stroke), Dysphagia (a language disorder characterized by partial impairment of comprehension or expression of spoken words) following Cerebral Infarction, Major Depressive Disorder (mental health condition characterized by a persistent, intense 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.
- Potential for harm · E2026-03-19 · 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 only kitchen reviewed for food safety. The facility failed to ensure stored canned goods had uncompromised seals and were free from dents.The facility failed to ensure the handwashing sink #2 of #2 garbage receptacle contained only paper towels.These failures could place residents at risk for food-borne illness, cross contamination, and infection.findings included: During an observation of the #1 handwashing sink's garbage receptacle on 03/17/2026 at 11:15 a.m., the following was revealed: #1 of #2 handwashing sinks had garbage receptacles that contained items other than disposable paper towels, which included styrofoam cups, used gloves, and coffee grounds.During an observation of the dry storage room on 03/17/2026 at 11:48 a.m., the following was revealed:1 Lemon pie filling or topping 116 oz (7 lbs. 4 oz) dent on the top seal, delivery date written 12/29/2025, no expiration date.3x…
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 before2026-03-19 · 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 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 three of four staff members (MA A, MA B and CNA C) and six of six residents (Resident #71, #89, #4, #13, #88 and #76) reviewed for infection control procedures. 1. The facility failed to ensure MA A performed hand hygiene after direct contact with Resident #71, while serving meals in the dining room. 2. The facility failed to ensure MA A disinfected the blood pressure cuff in between vital sign checks for Resident #89 and Resident #4. 3. The facility failed to ensure MA B disinfected the blood pressure cuff in between vital sign checks for Resident #13 and Resident #88. 4. The facility failed to ensure CNA C changed their soiled gloves and performed hand hygiene during incontinent care on Residents #76. These…
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 · D2026-03-19 · 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 observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 13 residents (Resident #55, and Resident #71) reviewed for rights. The facility failed to ensure the staff in the main dining room served Resident #55, and Resident #71, at the same time the other residents were served the lunch meal. These failures could place residents at risk of feeling like their dignity was being invaded or the facility was not their home. Findings included: Record review of Resident #55's admission MDS assessment, dated 03/06/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #55 had diagnoses which included: Cancer (degeneration of tissue), dementia (forgetfulness), and malnutrition (low in weight and nutrition). Resident #55 had moderate cognitive impairment 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.
- Potential for harm · D2026-03-19 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 5%, based on 34 opportunities, which involved 1 of 7 residents (Residents #47) and one of two staff (MA A) observed during medication administration for medication error. 1. MA A failed to administer Resident #47's Miralax Oral powder 17grm (for constipation) with the appropriate amount of fluid. 2. MA A failed to confirm Resident #47's MiraLAX Oral powder 17grm (for constipation) was administered. MA A left the cup of medication with Resident # 47. These failures could place residents at risk for not receiving the therapeutic dosages of their medications as ordered by the physician and a decreased health status. Findings include: Record review of Resident #47'squaterly MDS assessment dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #47had diagnosis which include:…
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 · D2026-03-19 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure 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 1 of 8 residents (Resident #71) reviewed for food and nutrition services. The facility failed to provide Resident #71 with her regular ground foods (mechanically altered diet that was prescribed for individuals who have difficulty chewing or swallowing food) as designated on her meal ticket on 03/17/2026. This deficient practice could place residents at risk for poor food intake, weight loss, and not having their nutritional needs met.The findings include: Record review of Resident #71's admission MDS assessment, dated 01/16/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #71 had diagnoses which included: heart failure (weak heart muscle), malnutrition (poor weight and nutrition), dementia (forgetfulness), and hypertension (increased blood pressure). Resident #71 had severe…
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 · E2025-11-26 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
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 nurse call system was accessible for residents to call for staff assistance through a communication system which relays the call directly to a staff member of a centralized staff work area for seven of ten residents (Residents #1, #2, #4, #5, #6, #7, and #9) reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light system in Residents #1, #2, #4, #5, #6, #7, and #9's rooms were in a position accessible to the residents on 10/07/25 on the 200, 300, and 400 halls. This failure could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: 1. Record review of Resident #1's Face Sheet, dated 10/07/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and need for assistance with personal care. Record review of Resident #1's Quarterly MDS assessment, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · D2025-11-26 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 free from physical restraints not required to treat the residents' medical symptoms as was possible for one of three residents (Resident #3) reviewed for restraints. The facility failed to ensure Resident #3 had physician orders for the bolster mattresses on her bed. This failure could place residents at risk of not having an environment free from physical restraints.Findings included: Record review of Resident #3's Face Sheet, dated 10/07/25, reflected she was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and seizures (uncontrolled movements). Record review of Resident #3's Quarterly MDS assessment, dated 9/01/25, reflected a BIMS score of 9 indicating moderate cognitive impairment. The resident had active diagnoses of muscle weakness and seizures. Record review of Resident #3's Comprehensive Care Plan, dated 10/05/25, reflected a plan of care for risk of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of six residents (Resident #3, #8, and #10) reviewed for respiratory care. The facility failed to ensure Resident #3 and #8's nebulizer mask was properly stored in a bag when not in use on 10/07/25. The facility failed to ensure Resident #10's CPAP mask was properly stored in a bag when not in use on 10/07/25. These failures could place residents at risk for respiratory infection and not having his respiratory needs met.Findings included: 1. Record review of Resident #3's Face Sheet, dated 10/07/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included chronic cough and shortness of breath. Record review of Resident #3's Quarterly MDS assessment, dated 9/01/25,…
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 before2024-05-22 · 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 observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #1, Resident #2, and Resident #3) of eight residents reviewed for quality of care. 1. The facility failed to ensure Resident #1's nasal cannula nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly. 2. The facility failed to ensure Resident #1's nasal cannula and humidifier were changed weekly. 3. The facility failed to ensure there was an Oxygen in Use sign outside Resident #1's door. 4. The facility failed to ensure Resident #2's nasal cannula was stored properly. 5. The facility failed to ensure Resident #3's mask for BiPAP (bilevel positive airway pressure - normalizes breathing by delivering pressurized air into the upper airway leading into the lungs)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-16 · tag F0657 — failed to keep the care plan current — patternDevelop 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 interviews and record reviews, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 1 of 6 residents (Resident #1 reviewed for Care Plans. The facility failed to ensure Resident #1 Care Plan was reviewed and updated quarterly. This failure could place residents at risk of their needs not being met. Findings included: Record review of Resident #1's electronic face sheet printed 4/16/2024 revealed 86 -year-old male admitted on [DATE] and discharged on 10/30/2022 with diagnosis that included but not limited to dementia(impaired ability to remember, think, or make decisions that interferes with doing everyday activities), chronic kidney disease stage 3(mild to moderate loss of kidney functions), benign prostatic hyperplasia with lower urinary tract symptoms(frequent or urgent need to urinate) Record review of Resident #1's quarterly MDS date 2/21/2024…
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 · D2024-04-16 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure the resident had the right to participate in the development and implementation of his person-centered plan of care for one (Resident #1) of five resident reviewed for person-centered plans of care. The facility failed to include Resident #1 in his Care Plan Conference. This failure could affect residents and place them at-risk by contributing to inadequate care. The findings included: Record review of Resident #1's electronic face sheet printed 4/16/2024 revealed an 86 -year-old male admitted on [DATE] and discharged on 10/30/2022 with diagnoses that included to dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), chronic kidney disease stage 3 (mild to moderate loss of kidney functions), and benign prostatic hyperplasia with lower urinary tract symptoms(frequent or urgent need to urinate). Record review of Resident #1's quarterly MDS date 2/21/2024 revealed a BIMS score of 13 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 · D2024-04-16 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 protect the confidentiality of personal health care information for one (CMA B) of three staff observed for confidentiality of records. The facility failed to ensure CMA B locked and closed the laptop during the medication pass exposing all resident on the hall's personal information. This failure could affect residents by placing them at risk for loss of privacy and dignity. The findings included: Observation on 04/16/24 at 12:40PM revealed the computer on Medication Cart 1 was unlocked and unattended on Hall 300. The computer was unattended while CMA B was in a resident room for approximately two minutes. There were residents and a house keeper walking past the unlocked computer which displayed the residents on hall 300's name and medication due. Interview on 04/16/24 at 12:43PM with CMA B revealed she had worked the facility for 4 months. She stated she was aware the computer should have been locked however she went to help a resident that needed assistance in the restroom. She stated normally she would…
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 before2024-04-16 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a sanitary environment for 1 (Residents #1) of 4 residents reviewed for environmental conditions. The facility failed to ensure Resident #1's bed was made with clean linens and was not wet and did not contain urine stains. The failure placed residents at risk for unsanitary living. Findings included: Record review of Resident #1's electronic face sheet printed 4/16/2024 revealed an 86 -year-old male admitted on [DATE] and discharged on 10/30/2022 with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), chronic kidney disease stage 3 (mild to moderate loss of kidney functions), and benign prostatic hyperplasia with lower urinary tract symptoms (frequent or urgent need to urinate). Record review of Resident #1's quarterly MDS date 2/21/2024 revealed a BIMS score of 13 which indicated the resident was cognitively intact. Review of Section GG…
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 · D2024-04-16 · 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 store all drugs and biologicals in locked compartments for one of four halls (Hall 300) reviewed for medication storage. On 4/16/2024, the facility failed to keep Medication Cart 1 locked on Hall 300. These failures placed 27 residents on Hall 300 at risk of drug diversions or misuse of medications. Findings included: Observation on 04/16/24 at 12:40PM revealed Medication Cart 1 was unlocked and unattended on Hall 300. All the drawers of Medication Cart 1 could be opened, and the medication was easily accessible due to the lock not being pushed in on the cart. The cart was unattended while CMA B was in a resident room for approximately two minutes. There were residents walking past the unlocked medication cart and a housekeeper on the hall working near the cart. Interview on 04/16/24 at 12:43PM with CMA B revealed she had worked the facility for 4 months. She stated she was aware the medication cart should have been locked; however, she went to help a resident that needed assistance in the restroom. She…
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 before2024-03-03 · 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 establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for two (CNA A and CNA B) of 8 CNAs reviewed for infection control. CNA A and CNA B failed to wear adequate PPE while repositioning COVID-19 positive Resident #1. CNA A failed to wear adequate PPE while delivering and setting up COVID-19 positive Resident #2's breakfast tray. CNA A and CNA B failed to perform hand hygiene while delivering and picking up breakfast trays from residents on the 300 hall. This failure placed residents at risk for infection and result in decline in health. The findings included: Review of Resident #1's quarterly MDS, dated [DATE], revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Her hearing, speech, and vision section revealed she usually made herself understood and usually…
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 before2023-10-26 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 9 of 20 rooms (Room # 106, 110, 112, 114, 118, 401, 408, 405, and 418), observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that resident rooms and handrails were cleaned and sanitized. These deficient practices could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings include: Observation of Room # 106 on 10/24/23 at 9:57 AM revealed a long brownish spill stain on one of the walls. The air-condition unit had dirt particles between the vents and there was an adult brief on the top of the unit. Under the bathroom sink there were grayish and brownish stains on the floor. Observation of Room # 110 on 10/24/23 at 10:03 AM revealed the room entry…
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 before2023-10-26 · 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 observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Residents #11, Resident #31, Resident #3, and Resident #16 of six residents observed for infection control. The facility failed to ensure that Resident #11's nasal cannula was off the floor. The facility failed to ensure CMA (certified medication aide) C sanitized the blood pressure cuff between Resident #3, Resident #16, and Resident #31. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: Review of Resident #3's Face Sheet dated 10/25/2023 reflected that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included essential primary hypertension, unspecified dementia, unspecified peripheral vascular disease (a slow and progressive…
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 · D2023-10-26 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #11) of six residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #11's rooms was in a position that was accessible to the resident. This failure could place the resident at risk of being unable to have their needs met or obtain assistance in the event of an emergency. Findings included: Review of Resident #11's Face Sheet dated 10/24/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), intermittent claudication (muscle pain due to lack of oxygen) of bilateral legs, right shoulder primary osteoarthritis (a type of arthritis that happens when…
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 · D2023-10-26 · tag F0635 — isolatedProvide doctor's orders for the resident's immediate care at the time the resident was admitted.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents had physician's orders for the resident's immediate care for one (Resident #11) of six residents reviewed for admission orders. The facility failed to obtain physician orders for oxygen supplement for Resident #11 at the time of admission. This failure could place the resident at risk of not receiving necessary care and services upon admission that could result to worsen condition. Findings included: Review of Resident #11's Face Sheet dated 10/24/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), intermittent claudication (muscle pain due to lack of oxygen) of bilateral legs, right shoulder primary osteoarthritis (a type of arthritis that happens when the cartilage that lines your joints is worn down and your bones rub against…
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 · D2023-10-26 · 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 observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 4 (Resident,#7, #11, #22, and #82) of 12 residents reviewed for Care Plans. The facility failed to ensure Resident #11, and Resident #22 were care planned for oxygen administration. The facility failed to accurately assess Resident #7's diagnosis of malnutrition by not including the resident's physician orders for weekly weigh-ins as an intervention on the care plan. The facility failed to accurately assess Resident #82's communication concerns and did not include the resident's physician orders for speech therapy as an intervention on the care plan. These failures could place…
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 · D2023-10-26 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 6 residents (Resident #7) reviewed for assisted nutrition and hydration. The facility failed to assess Residents #7's weight on a weekly basis per physician orders, and the resident experienced more than a 5% weight loss in a month. This failure could place resident at risk of experiencing a decline in health due to malnutrition. Findings included: Record review of Resident #7's Face Sheet dated 10/25/23 indicated she was an 82 -year-old female admitted on [DATE]. Relevant diagnoses included Protein - Calorie Malnutrition, and Muscle Weakness. Record review of Resident #7's Minimum Data Set (MDS) on dated 09/27/23 indicated she had a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). Record review of Resident #7's Active Physician Orders dated 10/25/23 indicated the resident had an active…
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 before2023-10-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 (Resident #11, #32, #64) of 3 residents reviewed for respiratory care. The facility failed to ensure Resident #11's and 64's nasal cannulas were bagged and failed to change Resident #32's humidifier on the oxygen concentrator, which exceeded the facility policy of 7 days. These failures could place the residents at risk of not having their respiratory needs met. Findings included: Review of Resident #11's Face Sheet dated 10/24/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified chronic obstructive pulmonary disease, intermittent claudication (muscle pain due to lack of oxygen) of bilateral legs, right shoulder primary osteoarthritis (a type of arthritis 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.
“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
$10,348 in federal fines across 1 penalty.
- $10,348 — penalty dated 2025-04-02
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 PRIORITY MANAGEMENT — 38 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 | 2.9 | +1.1 vs chain |
| Health inspection | 3 of 5 | 3.2 | -0.2 vs chain |
| Staffing | 2 of 5 | 1.6 | +0.4 vs chain |
| Quality measures | 5 of 5 | 3.4 | +1.6 vs chain |
The other 37 homes this chain runs (chain average 2.9★, 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 |
|---|---|---|---|---|
| BAUDER FAMILY INVESTMENTS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 33% | since 04/01/2024 |
| BOULWARE ST JAMES LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 33% | since 04/01/2024 |
| STEVEN BOULWARE FAMILY INVESTMENTS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 33% | since 04/01/2024 |
| BAUDER, KELLY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 8% | since 04/01/2024 |
| BAUDER, PARKER | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 8% | since 04/01/2024 |
| BOULWARE, THOMAS | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 8% | since 04/01/2024 |
| WALKER, KATIE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 8% | since 04/01/2024 |
| BAUDER, WILLIAM | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 04/01/2024 |
| BOULWARE, STEVEN | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 04/01/2024 |
| MILLER, BOBBIE | Individual | CORPORATE OFFICER | — | since 04/01/2024 |
| PATEL, MANOJ | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2024 |
| RODRIGUEZ, GENEVY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2024 |
| BRIDGEPOINTE FINANICAL SERVICES, LLC | Organization | ADP OF THE SNF | — | since 04/01/2024 |
| INNOVATIVE NURSE CONSULTING, LLC | Organization | ADP OF THE SNF | — | since 04/01/2024 |
| PMG REALCO-LEWISVILLE, LLC | Organization | ADP OF THE SNF | — | since 04/01/2024 |
| PRIORITY MANAGEMENT GROUP, LLC | Organization | ADP OF THE SNF | — | since 04/01/2024 |
| PROGRESSIVE REHAB SOLUTIONS, LLC | Organization | ADP OF THE SNF | — | since 04/01/2024 |
| BAUDER, MADISON | Individual | ADP OF THE SNF | — | since 04/01/2024 |
| BOULWARE, DOUGLAS | Individual | ADP OF THE SNF | — | since 04/01/2024 |
| BOULWARE, SANDRA | Individual | ADP OF THE SNF | — | since 04/01/2024 |
CMS files one row per role, so the 28 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $472K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 676036. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-19, 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 →
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