Chisolm Trail Nursing and Rehabilitation Center
107 North Medina Street, Lockhart, TX 78644 · For profit - Limited Liability company · 96 certified beds · (512) 398-5213 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 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — 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 (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $37,541 in federal fines (most recent 2024-08-31)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (1/5)
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) | 1 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 |
| 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 held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 14.2% | 15.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 0.4% | 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 | 1.3% | 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 | 3.8% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 19.1% | 14.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 16.5% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.2% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 12.8% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.3% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.8% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.4% | 25.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 0.0% | 12.3% | 12.0% | check this* — see note marked star below the table |
| Long-stay hospitalizations per 1,000 resident days | 3.09 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.77 | 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.
27.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.9% 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 23 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 0.27 therapist hours per resident per day in 2026Q1 — more than 39% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 | 27.7%CMS range 17.0–41.3 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 7.0–13.7 | 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 | 60.9% | 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 | 52.2% | 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 | 47.8% | 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 | 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 | 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 | 3.1% | 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 | 10.4%CMS range 6.3–17.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.27 | 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 96 beds and averages 69.3 residents a day — about 72% occupied, or roughly 27 beds typically open. It usually has some room. 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 2.72 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 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 2.28 hrs/resident/day on weekends vs 2.90 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.55 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · Kcited before2024-08-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #1) of three residents reviewed for pressure injuries. The facility failed to reinstate Resident #1's wound treatment orders after she was readmitted from the hospital on [DATE] until 07/16/24. Her wounds worsened and a new pressure injury was acquired during that timeframe. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 08/30/24 at 1:44 PM. While the IJ was removed on 08/31/24 at 12:55 PM, the facility remained at a level of actual no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing…
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 · D2026-04-08 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance for 2 (03/30/2026 and 03/31/2026) of 31 days reviewed for sufficient staffing. The facility failed to provide sufficient CNAs on 03/30/2026 and 03/31/2026 leaving the secured unit without a CNA on the overnight shift of 10 p.m. to 6 a.m., leaving residents without proper supervision and care. This failure could place residents at risk of inadequate supervision and an unsafe environment which could lead to falls, serious harm and injury, exacerbations of disease processes, and abuse and neglect. Findings included: Record review of Resident #1's admission record generated on 04/08/2026 reflected a [AGE] year old female…
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 · E2025-08-07 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in experimental research, and to formulate advance directives for 3 of 10 residents (Resident #1, #4 and #65) reviewed for advance directives. The facility failed to ensure that Resident #1's out of hospital DNR was uploaded to the electronic health record and the care plan was updated.The facility failed to ensure that Resident #4's out of hospital DNR was signed by the physician and uploaded to the electronic health record on [DATE].The facility failed to ensure that Resident #65's out of hospital DNR was signed by the physician and uploaded to the electronic health record on [DATE]. These failures could place residents at-risk of having their wishes dishonored, and of having CPR performed against their wishes. Findings included: Record review of Resident #1's Face sheet dated [DATE] reflected a [AGE] year-old female who was admitted to the facility 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 · Ecited before2025-08-07 · 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 for 1 of 1 kitchen and 1 of 1 nourishment room reviewed for food and nutrition services. 1) The facility failed to properly seal food product bags in the walk-in freezer to prevent exposure to air. 2) The facility failed to label and date food items in the walk-in freezer, and the nourishment refrigerator. 3) The facility failed to maintain the proper temperature of the refrigerator in the nourishment room. This failure could have placed residents at risk for food contamination and foodborne illness. Findings included: Observation of the kitchen's walk-in freezer on 08/05/2025 at 09:03 AM revealed several boxes of frozen food stacked on top of each other. The boxes were crushed, smashed, wet from condensation, and ice was piled on top of some of the boxes. Several boxes of frozen food were not properly sealed, exposed to air, and not dated. One box of frozen garlic bread was not properly sealed 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 · E2025-08-07 · tag F0926 — failed to keep the home smoke-free / fire-safe — patternHave policies on smoking.
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 it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety for 3 of 5 residents (Residents #5, Resident #20, and Resident #78) reviewed for smoking. The facility failed to keep Residents #5, Resident #20, and Resident #78's cigarettes and lighters in a safe place per their policy. This failure placed all residents at risk for serious injury, harm, and/or death due to possible fire or smoking inside the building. Findings Included: Resident #5 Record review of Resident #5's Face sheet dated 08/06/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included end stage renal disease, unsteadiness on feet, limitation of activities due to disability, atrial fibrillation (abnormal heart rhythm), chronic obstructive pulmonary disease (chronic progressive lung disease), dementia (memory, thinking, difficulty), low back pain,…
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 · D2025-08-07 · 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, interview and record review, the facility failed to develop and implement a comprehensive person-centered care that included measurable objectives and timeframes to meet the residents' medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment for 2 of 10 residents (Residents #1 and #7).1. The facility failed to ensure the care plan was updated when Resident #7's code status was changed from full code to DNR on [DATE].2. The facility failed to ensure the care plan was updated when Resident #1's code status was changed from full code to DNR on [DATE].This failure could place residents at-risk of having their wishes dishonored, and of having CPR performed against their wishes.Findings included:Record review of Resident #7's admission record, dated [DATE], reflected a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs), type 2…
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 before2025-08-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one of two residents (Resident #4) reviewed for pressure injuries. The facility failed to ensure wound care was performed as ordered by the wound care doctor for Resident #4. Resident #4 missed 6 wound care treatments in July 2025 and August 2025. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain.Findings included:Record review of Resident #4's admission record, dated 08/06/2025, revealed an [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform…
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 · D2025-08-07 · 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 observations, interviews, 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) (for Resident #8) to meet the needs of each resident for 1 of 1 medication storage room and 1 of 3 (hall 1 nurses' medication cart) medications cart reviewed for pharmacy services. The facility failed to ensure expired medications were removed from the medication storage room and the hall 1 nurses' medication cart on 08/07/2025. The facility failed to ensure that the narcotic count sheet accurately reflected the amount of Resident #8's phenobarbital (a controlled medication used in the treatment of seizures) stored in the hall 5 nurses' medication cart. This failure could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose, and/or adverse reactions from receiving medications past their expiration date. Findings included: 1.…
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 · D2025-08-07 · 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 ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 3 (hall 1 nurse's medication cart) Nurse's medication carts reviewed. 1. The facility failed to ensure the nurses' medication cart for hall 1 was secured by a lock when it was left unattended by LVN G on 08/07/2025.These failures could place residents at risk of illness or injury due to missing medication or if unattended medication were consumed. Findings included:An observation on 08/07/2025 at 10:23 AM on hall 1 revealed the nurses' medication cart for hall 1 was left unattended and unlocked.During an interview on 08/07/2025 at 10:25 AM with LVN G, she stated she was responsible for the hall 1 nurses' medication cart that was left unlocked. She stated she forgot to lock the medication cart when she walked down hall 1. She stated leaving the medication cart unlocked could negatively impact a resident because anyone could get into the medication cart and take something they are 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 · Dcited before2025-07-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. The facility failed to complete an accurate skin assessment on Resident #1 on 07/17/25 which did not include multiple red small scratches underneath both of her eyes. This failure could place residents at risk of skin integrity issues not being addressed, infection, and hospitalization. Findings included:Review of Resident #1's undated face sheet reflected [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, history of falling, and dementia. Review of Resident #1's quarterly MDS assessment, dated 05/07/25, reflected a BIMS score of 99, indicating she was unable to complete the interview due to her severe cognitive deficit.…
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 · E2025-06-05 · tag F0609 — failed to report abuse allegations — patternTimely 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, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect resulted in bodily injury, to other officials (including the State Agency) for 4 of 6 residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for abuse and neglect. 1. The facility failed to report to the State Agency an incident that involved Resident #1 on 05/25/2025 within the allotted timeframe. 2. The facility failed to report to the State Agency an incident that involved Resident #2 and Resident #3 on 04/06/2025. 3. The facility failed to report to the State Agency after x-ray results revealed Resident #4 sustained a fracture after a fall on 03/31/2025 within the allotted timeframe. This failure could place residents at risk for harm to include physical…
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 13 citations
- Potential for harm · D2025-06-05 · 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 residents had the right to be free from physical abuse and neglect for two (Resident #1 and Resident #3) of five residents reviewed for abuse and neglect. 1. The facility failed to ensure Resident #1 was not physically abused by FM on 05/25/2025 when FM hit Resident #1 after Resident #1 became agitated and hit the FM. 2. The facility failed to protect Resident #3 from physical abuse by Resident #2. Resident #3 wandered into Resident #2's room and was hit by Resident #2 after Resident #2 stated I'm going to hit you. These failures placed residents at risk of abuse, neglect, trauma, and psychosocial harm. Findings include: 1. Review of Resident #1's face sheet dated 05/28/2025 reflected a [AGE] year-old man admitted on [DATE] with diagnoses of unspecified dementia (cognitive functioning severe enough to affect daily life where type cannot be determined), depression (mood disorder characterized by persistent sadness), other specified arthritis…
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 before2025-03-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of three residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 had a physician's order for suctioning, and order for monitoring for secretions, or an order for when to replace the suction machine's cannister and tubing. This deficient practice could place residents at risk of aspiration, aspiration pneumonia, or hospitalization. Findings Included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including aspiration (inhaling something into your airway) of fluid as the cause of abnormal reaction, cerebral infarction (stroke), anoxic (lack of oxygen) brain injury, dysphagia (difficulty in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-11 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure resident rights for personal privacy for 4 of 6 residents (Resident # 6, Resident # 14, Resident #20, and Resident # 43) residents reviewed for personal privacy. The facility failed to knock on Resident #6, #14, #20, and #43's room when going into the residents' rooms. The deficient practice could affect all residents right to privacy in the facility and cause the resident to feel like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #6's Face Sheet dated 07/10/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6's diagnoses included senile degeneration of brain, protein deficiency, COVID, schizophrenia (mental disorder), major depressive disorder, nuclear cataract (hardening of the center part of the eye), mood disorder, abnormalities of gait and mobility, muscle wasting, expressive language disorder, 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 · E2024-07-11 · 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 observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 4 of 6 residents (Residents #10, Resident #60, Resident#131, and Resident #39) reviewed for the usage of wrist blood pressure monitor. LVN C and LVN D did not clean and disinfect the wrist blood pressure monitor while using it on Resident #10, Resident # 39, Resident #60, and Resident #131. This failure could place the residents at the facility at risk of transmission of disease and infection. Findings included: Review of Resident #10's face sheet dated 07/10/24 reflected, Resident #10 admitted to the facility on [DATE]. She was an [AGE] year-old female diagnosed with hypertension, atherosclerotic heart disease (plaque buildup in the artery walls), anemia, coronary artery disease (insufficient supply of blood to heart), peripheral vascular disease (a slow and progressive circulation disorder caused by…
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 · D2024-07-11 · 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 each resident 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 1 of 20 (Resident #15) residents reviewed for dining services in 1 of 1 dining room. The facility failed to promote Resident #15's dignity while dining when staff did not serve the resident their lunch tray at the same time as other residents at the same table for lunch on 07/09/2024. This failure could affect all residents who were eat in the dining room, by contributing to poor self-esteem, and unmet needs. Findings included: Review of Resident #15's Face Sheet dated 07/09/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included dementia (memory, thinking difficulty), abnormality of albumin (problems with liver and kidney function), epiphora due to insufficient drainage (excessive watering…
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 · D2024-07-11 · 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 observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 5 residents (Resident #47) reviewed for resident rights. The facility failed to ensure Resident #47's call light was within reach on 07/11/24. This failure could place residents at risk of needs not being met. Findings included: Record review of Resident #47's admission Record dated 07/11/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities), dysphagia (difficulty swallowing, cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), 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 · Dcited before2024-07-11 · 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 observations, interviews, and record review, the facility failed to ensure that one resident (Resident #57) out of five residents reviewed for activities of daily living received care and services for nail care. The facility failed to ensure that Resident #57's fingernails and/or toenails were cleaned and trimmed. This failure placed residents at risk for not receiving adequate care and services to prevent infection, injury, and diminished quality of life. Findings included: Record review of Resident #57's admission Record dated 07/11/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the atrial chambers of the heart, dementia (a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities), dysphagia (difficulty swallowing), and bipolar disorder (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 · D2024-04-12 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability of services of a lesser intensity, for two of four residents (Resident #1 and Resident #2) reviewed for specialized rehabilitative services, in that: The facility failed to: - Ensure Resident #1 received PT and OT as ordered. - Ensure Resident #2 was evaluated for PT, OT, or ST upon admission as ordered in her admission clinical records. This failure could place residents at risk of decline or decrease in their physical capabilities. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility for aftercare following joint replacement surgery. Her diagnoses included unsteadiness on feet, age-related physical debility, and other reduced…
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 · E2023-05-25 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment for 4 of 18 (resident # 8, # 24, # 45, and #55,) residents reviewed for accuracy of assessment. -The facility failed to ensure that for Residents # 8, # 24, # 45, and #55, the MDS assessment correctly noted the resident's lack of natural teeth, tooth fragments, and/or dentures. -The facility failed to accurately assess Resident #24 for his mental illness (qualifying diagnoses) on his annual MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: Resident # 8 Record review of Resident #8's face sheet, dated 05/25/2023, reflected a-[AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included, end stage renal diseases (kidney failure) heart failure, lack of coordination (inability to walk),…
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 before2023-05-25 · 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 food preparation and storage in that: -One of one commercial can opener was not kept clean and in a sanitary condition. -The facility failed to ensure expired food items were removed from the walk-in cooler. -All food items in walk in cooler were properly sealed, labeled and dated with expiration date. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease. Findings include: Kitchen observation and interview on 05/23/23 between 8:30AM and 8:40AM with the Dietary Manager, revealed the following- - The commercial can opener had a greasy dark substance around the cutting blade and the blade holder. The Dietary Manager said it need to be cleaned. - The walk-in cooler had two large bags of shredded cabbage with liquid substance at the bottom of the bag. The bags were dated 04/28/23. Interview with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-25 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 coordinate assessments with the (PASARR) program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort. in that -The facility failed to update the PASRR Level 1 forms for Resident #24 after a diagnoses of mental illness This failure could place residents requiring PASRR services at risk of not having their special needs assessed and met by the facility. Findings include: Resident #24 Record review of Resident #24's face sheet, dated 05/25/2023, revealed a-[AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included seizures, bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs), Dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) anxiety, abnormal gait, and lack of coordination (inability to walk). Record review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-25 · 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 observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1of 5 residents (Resident #45) reviewed for ADLs. The facility failed to ensure Resident #45 was provided personal grooming (shower and shaving) by facility staff. This failure could place residents at risk for discomfort, and dignity issues. Findings include: Resident #45 Record review of Resident #45's face sheet, dated 05/25/2023, revealed a-[AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included end stage renal diseases (kidney failure) heart failure, lack of coordination (inability to walk), Dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), cerebral infarction, (a brain lesion in which a cluster of brain cells die limiting blood…
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 · D2023-05-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 18 residents reviewed for unnecessary medications. (Resident #55) The facility failed to have an appropriate diagnosis or adequate indication for the use of Resident #55's Seroquel (antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder). This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings include: Record review of Resident #55's face sheet dated 05/25/2023 indicated he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnosis included Hypertensive heart disease with heart failure, unspecified dementia, unspecified…
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
$37,541 in federal fines across 1 penalty.
- $37,541 — penalty dated 2024-08-31
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 DIVERSICARE HEALTHCARE — 44 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 | 3 of 5 | 2.6 | +0.4 vs chain |
| Health inspection | 3 of 5 | 2.5 | +0.5 vs chain |
| Staffing | 1 of 5 | 3.0 | -2.0 vs chain |
| Quality measures | 5 of 5 | 3.5 | +1.5 vs chain |
The other 43 homes this chain runs (chain average 2.6★, per CMS)
Showing 40 of 43; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DIVERSICARE LEASING LP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/04/2006 |
| ADVOCAT FINANCE, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/18/1996 |
| DAC NEWCORP INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/04/2022 |
| DIVERSICARE HEALTHCARE SERVICES LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/10/1994 |
| DIVERSICARE MANAGEMENT SERVICES LP. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/10/1996 |
| PERKINS, TIFFANY | Individual | W-2 MANAGING EMPLOYEE | — | since 03/27/2017 |
| KOHN, BRIAN | Individual | CORPORATE DIRECTOR | — | since 11/19/2021 |
| RATNER, ERAN | Individual | CORPORATE DIRECTOR | — | since 11/19/2021 |
| BODIE, REBECCA | Individual | CORPORATE OFFICER | — | since 03/02/2020 |
| NEE, STEPHEN | Individual | CORPORATE OFFICER | — | since 02/20/2023 |
| WEISHAAR, MATTHEW | Individual | CORPORATE OFFICER | — | since 12/01/2003 |
| DLC GP LLC | Organization | GENERAL PARTNERSHIP INTEREST | — | since 04/04/2022 |
| DMS GP LLC | Organization | GENERAL PARTNERSHIP INTEREST | — | since 04/04/2022 |
| CHUDLEIGH, JAMES | Individual | ADP OF THE SNF | — | since 10/21/2024 |
7 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 $693K paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
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 675053. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-07, 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 →
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