Hansford County Hospital District dba Lakeridge Nu
4403 74th St, Lubbock, TX 79424 · For profit - Corporation · 90 certified beds · (806) 795-0668 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)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $30,561 in federal fines (most recent 2024-12-09)
- its payroll-based staffing rating is low (1/5)
- 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) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
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 | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 38.8% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.7% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.8% | 0.8% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 2.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 3.3% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 35.0% | 14.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.8% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.6% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.6% | 3.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 15.6% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.6% | 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 | 100.0% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 15.0% | 25.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.7% | 12.3% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 3.18 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.99 | 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.
36.6% 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 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% 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 | 36.6%CMS range 23.4–53.1 | 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 | 10.9%CMS range 8.0–15.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 3.9% | 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 | 3.9% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.10 | 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 90 beds and averages 60.1 residents a day — about 67% occupied, or roughly 30 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.97 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.20 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.78 hrs/resident/day on weekends vs 3.05 on weekdays — 9% thinner on weekends. RN hours go from 0.21 to 0.16 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · Kcited before2024-12-09 · 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 observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 14 of 74 residents (Resident #3, #11, #12, #19, #20, #24, #28, #38, #40, #44, #47, #58, #62, and #65) reviewed for call lights. The facility failed to ensure residents were equipped with a fully functioning call light system in room [ROOM NUMBER] and room [ROOM NUMBER]. Resident #11 had a diagnosis of type 2 diabetes and COPD (Chronic obstructive pulmonary disease), both which would require immediate attention if Resident #11 needed oxygen, or his blood sugar fell too low or got too high. Resident #12 had a diagnosis of type e2 diabetes which would require immediate attention if blood sugar were to get too high or too low. There were no frequent rounds being completed. These failures could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-12 · 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 received the necessary services to maintain good grooming, and personal hygiene for 1 of 7 residents (Resident #1) reviewed for ADL care.The facility failed to ensure Resident #1 was cleaned of bowel movement and urine on 5/10/2026 and on 5/11/2026.This failure could place the residents at risk for skin breakdown, infection and poor self-esteem.The findings include:Record review of Resident #1's face sheet revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had a medical history of cerebral ischemia (lack of blood flow deprives the brain of vital oxygen and glucose) , unspecified dementia (when a patient exhibits clear signs of cognitive decline such as memory loss, impaired reasoning, or personality changes severe enough to affect daily life), encounter for attention to other artificial opening of urinary tract (management,…
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 · E2026-05-01 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of all medications to meet the needs of the residents and establishes a system of records of receipt and disposition of all drugs in sufficient detail to enable an accurate reconciliation for 1 of 1 medication pass reviewed for pharmaceutical services in that:1. LVN A failed to document medications given on the EMAR immediately after administration to each resident during the nighttime medication administration on 4/30/26.2. LVN A failed to use the EMAR when she administered medications to residents during the nighttime medication administration on 4/30/26 and instead used a handwritten log as reference.These failures could place residents at risk of having their medications diverted and/or receiving the incorrect dosage.Findings included: Record review of LVN A's handwritten medication log, undated, revealed each resident's name and room number, and an abbreviated medication name was listed on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-01 · 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
Based on observation and interview 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 5 of 7 residents (Residents #1, #2, #3, #4, #5) and 1 of 1 staff (LVN A) reviewed for infection control. LVN A failed to sanitize hands between residents during medication administration for Residents #1, # 2, #3, #4, and #5 on 4/30/26.This failure could place residents at risk for spread of infection and cross contamination. Findings included:During an observation of medication pass on 4/30/26 at 9:00 PM, LVN A prepared medications for Resident #1 and administered medications. LVN A did not sanitize her hands before or after medication administration. During an observation of medication pass on 4/30/26 at 9:13 PM, LVN A prepared medications for Resident #2 and administered medications. LVN A did not sanitize her hands before or after medication administration. During an observation of medication pass on 4/30/26 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-01 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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, observation, and record review, the facility failed to ensure all residents were treated with respect and dignity for 1 of 7 residents (Resident # 1) reviewed for dignity.LVN A failed to treat Resident #1 with respect and dignity when she told Resident #1 to go to his room or to go outside and smoke when he asked for medications and when he was talking to staff and visitors in the dining room. This failure placed residents at risk of emotional distress, embarrassment, and lower self-esteem. Findings included:Record review of Resident #1's face sheet dated 4/30/26, revealed Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Acute respiratory failure with hypoxia (lack of oxygen in the bloodstream), chronic pain due to trauma, major depressive disorder (mental illness), chronic obstructive pulmonary disorder (severe breathing difficulties), anoxic brain damage (damage to the brain due to loss of oxygen), other…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 1 medication carts (Station 1 Cart) observed in the facility. The facility failed to ensure the Station 1 medication cart was secured when unattended on 4/30/26.This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversion. Findings included: During an observation on 4/30/26 at 8:14 PM the Station 1 medication cart was observed in the station 1 hallway with the lock popped out unattended and without a staff present. LVN A was observed coming out of a resident room and approaching the medication cart.During an observation and interview on 4/30/26 at 8:33 PM the Station 1 medication cart was observed in Station 1 hallway with the lock popped out unattended and without a staff present. LVN A was observed in Resident room [ROOM NUMBER]-B helping another staff transfer a resident into their bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-05 · 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 observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in a locked compartment for 1 of 2 nurse carts (Nurse Cart A) reviewed for medication storage. The facility failed to ensure Nurse Cart A was locked when not in use. This failure could place residents at risk of having access to unauthorized medications and lead to an increased risk for drug diversion and possible harm. The findings included: During an observation on 03/03/26 at 9:38 AM, Nurse Cart A was observed unlocked and unattended on Hall 2. No residents or staff were present by the nursing cart. During an observation on 03/03/26 at 12:15 PM, Nurse Cart A was observed unlocked and unattended on Hall 2. No residents or staff were present by the nursing cart. During an interview on 03/03/26 at 12:18 PM, LVN A stated she did not know why Nurse Cart A was unlocked in Hall 2. LVN A confirmed wound care supplies were available for use in Nurse Cart A by opening the cart. LVN A stated she had been trained on locking the medication and nursing carts when 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 · D2026-03-05 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to provide or obtain laboratory services only when ordered by a physician for 1 of 24 residents (Resident #8) reviewed for laboratory results in that:The facility failed to ensure Resident #8's Dilantin (Phenytoin) blood level was drawn monthly on the 21st of each month, as ordered by the physician, in January 2026 or February 2026.The facility failed to ensure Resident #8's Keppra (Levetiracetam) blood level was drawn monthly on the 21st of each month, as ordered by the physician, in January 2026 or February 2026. This failure could place residents with laboratory work orders at risk of not having their medical needs met. Findings include: Resident #8 Record review of Resident #8's electronic face sheet dated 03/03/2026 revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include the following: Epilepsy, unspecified, not intractable without status epilepticus (brain disorder characterized by recurrent episodes 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 before2026-03-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #41) reviewed for infection control. The facility failed to ensure Resident #41's room had clear signage regarding Enhanced Barrier Precautions (EBP). This failure could place residents at risk for cross contamination and infection. The findings included: Record review of the face sheet for Resident #41, dated 03/05/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: peripheral vascular disease (poor circulation), insomnia (sleep problems), and acute upper respiratory infection. Record review of the quarterly MDS assessment for Resident #41, dated 12/02/25 revealed Resident #41 had a BIMS score of 15 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 · Ecited before2025-09-05 · 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 3 of 3 residents (Resident #1, Resident #2 and #3) reviewed for infection control.1. CNA A failed to change gloves when going from dirty to clean when providing incontinence care for Residents #1, #2, and #3. These failures could place residents at risk for cross contamination and infection. The findings include: Resident #1 Record review of the admission record for Resident #1, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (a group of permanent movement disorders that affect brain-controlled muscle functions), schizoaffective disorder, bipolar type (mental health disorder) and anemia (not enough red…
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 · E2025-01-28 · 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 interviews 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, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Abuse Coordinator for 3 of 6 residents (Resident #1, #2, and #3) reviewed for abuse. A. The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding Resident #1 being fed forcibly by CNA A on an unknown date. B. The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding Resident #2 being transferred in a rough manner (chucked in the bed) by CNA A on an unknown date. C. The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding Resident #3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · E2024-12-09 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide a private space for the resident's monthly Resident Council meetings for 13 of 13 anonymous residents who attended Resident Council meetings. (Resident Council 12/04/2024). The facility failed to provide a private place for residents to be able to hold Resident Council Meetings monthly. This failure could result in issues affecting the residents' feeling that their grievances are not being acted upon and could place all residents who attend the Resident Council meetings at risk for feelings of powerlessness and decreased self-worth. The Findings included: During the confidential Resident Council interview on 12/04/2024 at 9:45 AM. the thirteen residents in attendance stated they had no privacy during their meetings. The meeting space was arranged by the Activity Director and the meeting space was held in the front lobby. The front lobby had the front door, the Administrator's office, and the BOM's office. Even though there was a sign on the wall outside of the front door informing staff the 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 · Ecited before2024-12-09 · 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 observations, interviews, and record review, the facility failed to ensure that each residents environment remained as free from accident hazards as possible for 2 of 27 residents (Resident #12, Resident #28,) and reviewed for accidents. 1. The facility failed to ensure 3 resident rooms (rooms [ROOM NUMBER]) did not have electrical outlets protruding from the wall. 2. The facility failed to ensure 1 resident room (room [ROOM NUMBER]), where Resident #12 resided, did not have an electrical outlet protruding from the wall with exposed wires. Resident #12 had a BIMS score of 03, indicating she had severe cognitive impairment, and she was able to self-ambulate in her wheelchair. This failure could place residents at risk for fires, physical harm, electrocution, pain, mental anguish, emotional distress, and injury. Findings included: Resident #12 Record Review of Resident #12's face sheet dated 12/04/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses:…
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 · E2024-12-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice for 3 (Resident #50, Resident #68, Resident #35) of 7 residents reviewed for respiratory care. The facility failed to follow their policy for proper storage of oxygen tubing for Resident #50, Resident #68, and Resident #35. This failure could place residents at risk for respiratory compromise and infection. Findings included: Resident #50 Review of Resident #50's face sheet revealed a [AGE] year-old female with an original admission date of 06/16/23 with the following diagnoses: Atherosclerotic Heart Disease (disease of the heart's major vessels), Cognitive Communication Deficit (inability to effectively communicate needs), Chronic Obstructive Pulmonary Disease (airflow blockage and breathing-related problems), Type II Diabetes Mellitus (abnormally elevated blood sugar levels), Heart Failure (heart condition),…
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 · E2024-12-09 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Puree) at 1 of 1 meal observed (12/03/24 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews 5 of 14 residents voiced concerns related to food palatability. The residents stated the food did not taste good and the residents did not like eating the facility food. One resident stated she wasn't sure if the cooks knew how to follow a recipe. One resident stated the food was very bland with no taste. On 12/03/24 at 10:50 AM the Dietary Manager was informed of a request for a test tray for the noon meal. Observation on 12/03/24 at 1:07 PM the test trays arrived at the conference room and sampling…
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 before2024-12-09 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) The facility failed to keep refrigerator handles clean 2) The facility failed to properly store a cupcake pan. 3) The facility failed to properly store food in the pantry and refrigerator. These failures could place residents at risk for food contamination and foodborne illness. The findings included: Observation during a kitchen tour on 12/03/24 beginning at 9:20 AM revealed 5 fridge handles that had dry, sticky substances on the inside handle, a cupcake pan stored on the bottom shelf right side up and 1 bag of enriched farina hot cereal, opened date of 12/02/24, observed in a bag that was not fully sealed in the pantry. Interview on 12/03/24 at 9:29 AM, the DM stated she did not know why the refrigerator handles were not clean and stated the refrigerators are cleaned every Sunday. The DM stated the food should be stored fully sealed in the kitchen…
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 · E2024-12-09 · tag F0813 — patternHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 4 of 4 refrigerators reviewed for food safety (room [ROOM NUMBER], 122, 133, 142). The refrigerator located in room [ROOM NUMBER] did not have an up-to-date temperature log nor did it have a thermometer inside of the refrigerator. The refrigerator contained undated perishable food items. The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer inside of the refrigerator. The refrigerator contained undated perishable food items. The refrigerator located in room [ROOM NUMBER] did not have an up-to-date temperature log nor did it have a thermometer inside of the refrigerator. The refrigerator contained undated perishable food items. The refrigerator located in room [ROOM NUMBER] did not have an up-to-date temperature log nor did it have a thermometer inside of the refrigerator. The refrigerator contained…
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 · D2024-12-09 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 1 of 1 resident (Resident #51). The facility failed to ensure 1 of 1 resident were provided a copy of the grievance that Resident #51 had filed, upon request, Resident #51 had the right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances, decreased quality of life, and feeling of hopelessness. Findings included: Resident #51: Resident #51: Record review of Resident #51 face sheet revealed an admission date of 04/08/2024 with a BIMS (Brief Interview for Mental Status) of thirteen, meaning that Resident #51's cognition is intact. Resident #51 had a diagnosis that included: acute respiratory failure (cannot maintain normal levels of oxygen and carbon dioxide in the blood), pain in the left wrist, morbid obesity, major depression disorder, dysthymic disorder (mild but long term form of depression), heredity & idiopathic neuropathy…
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 before2024-12-09 · 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 observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 2 of 2 medication carts (Station 1 medication cart, and Station 2 medication cart), reviewed for medication storage. 1. The medication cart assigned to Station 1 had loose pills. 2. The medication cart assigned to Station 2 had loose pills. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions. The findings included: 1. On 12/03/24 at 5:44 PM an observation of the medication cart for Station 1 was made with MA A. Three loose pills were found in the medication cart drawer. MA A placed the loose medications in a dispensing cup and the ADM identified the medications as Carbidopa/Levodopa 25-100 (1/2 tablet), Carbamazepine 200 mg (1 tablet) and Xarelto 200 mg (1 tablet). MA A and LVN B destroyed the loose medications in the sharps container and documented the destruction in the electronic record. During an interview on 12/09/24 at 11:23 AM with MA A, she stated there should not be loose…
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 before2024-12-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 (Resident #1 and Resident #61) of 3 residents and 1 (LVN A) of 2 staff reviewed for infection control. LVN A failed to perform hand hygiene between glove changes while providing wound care for Resident #1. LVN A failed to perform hand hygiene following a wound care procedure for Resident #1. LVN A failed to perform hand hygiene between glove changes while providing wound care for Resident #61. These failures could place residents at risk for spread of infection and cross contamination. Findings included: Resident #1 Record review of face sheet for Resident #1 revealed an [AGE] year-old male admitted to the facility 02/18/22 with the following diagnoses: Senile Degeneration of Brain (mental deterioration associated with advanced age), Dysphagia (difficulty swallowing),…
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 · D2024-06-11 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 6 resident rooms (room [ROOM NUMBER]) located on 1 of 2 facility corridors (East Hall): 1)Roaches were observed crawling on the walls and floor in 1 of 6 resident rooms (room [ROOM NUMBER]) located on 1 of 2 facility corridors (East Hall), and 2) The pest control program was further compromised due to the facility having harborage areas that were not repaired, clean and/or orderly (hand sink cabinetry and adjacent wall area, clutter). These failures could place residents at risk for infections. The findings include: During confidential resident interviews, 4 of 6 residents stated they had observed roach activity in the facility. One resident stated, I've seen them in the bathroom, closet and bed area. I've seen new hatchlings. He further stated housekeeping in his room varies and could go three or four days without housekeeping coming to his room. He…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-11-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1)The facility failed to ensure foods were processed, stored, and pureed under sanitary conditions. 2) The facility failed to ensure Dietary staff ensured food and non-food contact surfaces were clean. 3) The facility failed to ensure staff washed their hands in a sanitary manner. 4) The facility failed to ensure raw meat was thawed in a safe and sanitary manner. These failures could place residents at risk for food contamination and foodborne illness. The findings included: - The following observations and interviews were made during a kitchen tour on 11/06/23 that began at 9:17 AM and concluded at 10:10 AM: A large tube of frozen hamburger meat in a pan on the food preparation counter. It was not thawing in running water. There was no water in the pan. The drink gun spout had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-08 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
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 the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 7 of 22 residents (Residents #2, #7, #22, #25, #33, #37, and #57) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Residents #2, #7, #22, #25, #33, #37, and #57 prior to administering melatonin (sleep aide). This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the benefits and risks of the medications prescribed. Findings included: Resident #2 Record review 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 · Ecited before2023-11-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible in 9 of 26 resident rooms (119, 120, 132/133, 134/135, 138, 139/140) located on 2 of 2 nurse stations (Station 1 and 2) and 1 of 1 beauty shop and reviewed. The facility further failed to accurately assess each resident's status for safe smoking for one of one resident (Resident #49) reviewed for smoking assessment. The facility failed to maintain resident use hot water at safe and comfortable temperatures. Resident-use hot water was not reliably controlled. Hot water temperatures ranged from 117.9 to 124.2 F at 9 of 26 resident room hand sinks located on Stations 1 and 2 and beauty shop shampoo basin. The facility failed to ensure used needles were transported in a safe manner in resident use areas at 1 if nurse stations (Station 2), and The facility failed to complete a safe smoking assessment for Resident #49 upon admission and monthly. 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 · E2023-11-08 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 6 out of 30 (10/15/23, 10/28/23,10/29/23, 10/31/23, 11/04/23, and 11/05/23) reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: 10/15/23, 10/28/23,10/29/23, 10/31/23, 11/04/23, and 11/05/23 This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of the facility's employee roster dated 10/31/23 revealed there were two RNs employed at the facility. Record review time sheet for DON dated 11/6/23 revealed no hours worked for 10/15/23, 10/28/23,10/29/23, 10/31/23, 11/04/23, and 11/05/23. Record review time sheet for RN A dated 11/6/23 revealed no hours worked for 10/15/23, 10/28/23,10/29/23, 10/31/23, 11/04/23, and 11/05/23. During an interview on 11/08/23 at 11:30 AM with the DON she stated she was currently the only RN employed. She stated she works Monday through Friday 08:00 AM to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-08 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments on for 2 medication cart (South-hall Medication Cart and North-hall Medication Cart)) of 2 carts reviewed for storage and 1 treatment cart (Station 2) of 2 treatment carts. The facility failed to ensure two narcotic boxes for 1 medication cart was always locked. The facility failed to ensure that medications were properly labeled and stored properly. The facility failed to ensure treatment cart medications were stored in a secure locked manner, while unattended, for 1 of 2 treatment carts (Station 2). This failure could place residents at risk of having access to unauthorized narcotic medications and/or lead to possible harm, drug overdose, or drug diversions. Findings included: On 11/06/2023 at 4:07 pm, an observation and interview was done for medication cart check and medication pass for the south cart on south hall with LVN E. During the observation the narcotic box…
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 before2023-11-08 · 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 implement and maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. 2 of 2 staff (LVN E and MA) and 1 of 22 LVN E and MA failed to implement effective handwashing techniques during medication pass. The facility failed to ensure that dressing change procedures were conducted in a sanitary manner for Resident #21. These failures could affect residents and staff members by placing them at risk for the transmission of communicable diseases, and infections. Findings include: On 11/7/2023 at 8:22 am an observation was completed with MA during medication pass. MA did not wash hands or use hand sanitizer prior to preparing medications and did not use a clean paper towel when she washed hands prior to administering the medications to resident. MA turned on water and put soap in hands, washed her hands for 23 seconds,…
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 before2023-11-08 · 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 facility was adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area in 5 of 11 resident rooms (104, 107, 116, 119 and 120) on Station 2 (East wing). 1)The facility failed to ensure that 5 of 11 resident rooms had operable call systems at the bedroom and toilet. These failures could place residents at risk of not receiving assistance when needed. The findings include: On 11/6/23 at 11:18 AM an interview was conducted with Maintenance Supervisor. He stated sometimes the facility had problems with the call system. Repairmen have told the facility in the past that parts for the system cannot be obtained because they stopped making them. On 11/6/23 at 3:25 PM an interview was conducted with LVN A. She stated that some of the call lights do not illuminate at the Station 2 nurses station call board. 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 · D2023-11-08 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with an accurate PASRR Level I for 1 of 15 residents (Resident #54) reviewed for PASRR screening, in that: Resident #54 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of mental illness. This failure could place residents with an inaccurate PASRR Level 1 Evaluation and no PASRR Level 2 Evaluation at risk for not receiving care and services to meet their needs. The findings included: Record review of Resident #54's electronic face sheet dated 11/07/2023 revealed a [AGE] year-old female most recently admitted to the facility on [DATE]. The face sheet listed under Diagnosis Information a diagnosis of Major Depressive Disorder. Record review of Resident #54's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of Major Depressive Disorder. Additionally, under Section C Cognitive…
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 · D2023-11-08 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 2 residents fed by gastrostomy tube (Resident #21). 1)The facility failed to ensure nursing staff provided G-tube (gastrostomy tube) care in a sanitary manner and followed physician orders for Resident #21. These failures could result in the spread of resident infections. The findings include: Record review of the Order Summary Report dated 11/6/23 for male Resident #21 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of dysphagia oropharyngeal phase (swallowing disorder), gastrostomy status (nutrition delivered through abdominal wall), contracture, unspecified, joint (reduced joint flexibility), personal…
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 · D2023-11-08 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly in 1 of 2 dumpsters (west) and dumpster area. The facility failed to maintain the dumpster/refuse disposal containers and area in a manner that effectively prevented the harborage and attraction of pest. This failure could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility. The findings include: On 11/6/23 at 10:02 AM an observation was made at the dumpster area. There was a mattress with a torn cover on the ground behind the two dumpsters. There was trash scattered around the dumpster area that was approximately in an L shape pattern of more than 20 feet each way behind the dumpsters. The area had trash, which included cups, weeds, shopping cart, and the mattress with the torn cover. There was also a large amount of trash along the fence line in the area that included trash and cigarette butts. Behind the oxygen storage building that was adjacent to the dumpsters there was an approximately 5' x 8' area…
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
$30,561 in federal fines across 1 penalty.
- $30,561 — penalty dated 2024-12-09
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 GULF COAST LTC PARTNERS — 20 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 | 2 of 5 | 2.4 | -0.4 vs chain |
| Health inspection | 3 of 5 | 3.0 | ≈ chain avg |
| Staffing | 1 of 5 | 1.6 | -0.6 vs chain |
| Quality measures | 3 of 5 | 2.6 | +0.4 vs chain |
The other 19 homes this chain runs (chain average 2.4★, 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 |
|---|---|---|---|---|
| HANSFORD COUNTY HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/01/2018 |
| LUBB-TEX PROPERTIES, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 04/01/2018 |
| BAILEY, JONATHAN | Individual | CORPORATE OFFICER | — | since 02/01/2010 |
| LAKERIDGE LTC PARTNERS, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2018 |
| BERGERON, BOBBY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2018 |
| NICHOLSON, LOUIS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2018 |
| JONES, JAMES | Individual | ADP OF THE SNF | — | since 12/27/2022 |
| MCPHERSON, MICHAEL | Individual | ADP OF THE SNF | — | since 01/01/2015 |
CMS files one row per role, so the 10 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 675853. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.