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Windmill Village Rehabilitation & Care Center

507 Martin Luther King Blvd, Lubbock, TX 79403 · Government - Hospital district · 120 certified beds · (806) 744-1113 Medicare & Medicaid certified

Call the home — (806) 744-1113 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0565)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Urgent care / clinic
406 Martin Luther King Blvd · (806) 767-9744 · Call to confirm hours
Pharmacy
1824 Parkway Dr · (806) 767-9999 · Call to confirm hours
Grocery
2630 Parkway Dr · (806) 765-8013 · Call to confirm hours
Park
SantaLand0.6 mi
Typically dawn to dusk
Place of worship

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 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased11.1%15.8%15.4%better
Long-stay residents who lose too much weight0.7%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms3.8%2.4%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.1%3.3%3.3%better
Long-stay residents whose ability to walk worsened8.1%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.3%18.0%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers2.4%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control7.0%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table5.2%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine90.0%88.0%79.4%better
Short-stay residents rehospitalized after admission16.9%25.7%22.6%better
Short-stay residents with an outpatient ER visit4.7%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days1.912.171.67worse
Long-stay outpatient ER visits per 1,000 resident days1.352.061.80better

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.

43.7% 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 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

43.7%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
67.6%U.S. median 56.6%
Met the expected recovery
0.65U.S. median 0.31
Therapy hours / resident / day
0.34hours / resident / day
Physical therapy
0.27hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 67.6% 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 37 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 0.65 therapist hours per resident per day in 2026Q1 — more than 90% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF43.7%CMS range 32.5–58.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.0–13.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge67.6%56.6%Oct 2024–Sep 2025CMS 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 discharge56.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge51.4%50.0%Oct 2024–Sep 2025CMS 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 identified98.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened9.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.5%CMS range 4.2–16.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.341.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.43
RN hours/ resident / day
0.69
LPN hours/ resident / day
1.98
Aide hours/ resident / day
3.11
Total nurse hours/ resident / day
0.35
RN hoursweekends
61.6%
Total nursing turnover
53.8%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 104.7 residents a day — about 87% occupied, or roughly 15 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 3.24 on weekdays — 14% thinner on weekends. RN hours go from 0.46 to 0.35 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

3
deficiencies at the latest standard inspection (2026-07-09)
10
at the previous standard inspection (2025-05-20)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · Ecited before2026-07-09 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews, the facility failed to treat residents with respect, dignity, and care in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality for 11 of 11 confidential residents in that: The facility failed to ensure staff were not utilizing their personal cell phones while providing care, which included assisting residents with their showers and performing peri-care. The deficient practice could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings include:At an undisclosed date and time eleven confidential residents stated the use of cell phones by CNAs while performing care made them feel ignored, not a priority, embarrassed, concerned that the CNA could make a mistake due to distraction by the cell phone conversation, and, most of all, their privacy was violated. The eleven confidential residents stated the use of cell phones by CNAs occurred on every shift. The confidential residents stated staff utilized their cell…

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

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Ecited before2026-07-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to ensure the fryer was free of build up and grime. The facility failed to ensure the toaster was free of build-up and grime. The facility failed to ensure the wall behind the dishwashing station was free of build-up and grime.The facility failed to ensure hot holding pans/cookie sheets were free of build-up and grime.The facility failed to ensure all canned food items had expiration or use-by dates. The facility failed to ensure all pantry food items had expiration or use-by dates. The facility failed to ensure prepared gravy had an expiration or use-by date. The facility failed to ensure prepared pureed chicken had an expiration or use-by date. These failures could place residents who received meals and/or snacks from the kitchen at risk of food…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Dcited before2026-07-09 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 15.38 percent based on 4 errors out of 26 opportunities, which involved 2 (Resident #107 and Resident #45) of 3 residents reviewed for medication administration.-MA A failed to give Resident #107's dose of the medication Metoprolol Tartrate at the ordered time, resulting in a late dose. -MA A failed to give Resident #45's dose of the medication Levetiracetam at the ordered time, resulting in a late dose. -MA A failed to give Resident #45's medication Lisinopril according to physician's orders when she administered the medication outside the ordered vital sign parameters. -MA A failed to verify the correct dosage for Resident #45's medication Pantoprazole prior to administering the medication, resulting in Resident #45 being underdosed. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative…

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

    Pharmacy Service Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2025-11-25 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolated
    Have 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 observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 3 residents reviewed for smoking. (Resident #1)The facility failed to ensure staff followed the smoking policy and took residents out to smoke in designated smoking area. This failure could place residents at risk of injury or harm.Findings included:Record review of Resident #1's face sheet undated revealed she was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), emphysema (lung condition that causes shortness of breath), hypertension (high blood pressure), shortness of breath, anxiety (feeling of fear and worry), and tobacco use.Record review of Resident #1's quarterly MDS assessment dated [DATE], revealed she had a BIMS score of 12, which indicated she had moderate cognitive impairment. The MDS indicated Resident #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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-29 · tag F0644 — isolated
    Coordinate 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 interviews, and record review, the facility failed to incorporate recommendations from a PASRR level II determination and the PASRR evaluation report for 1 of 5 residents (Resident #1) reviewed for PASRR. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed for a better quality of life.Record review of Resident #1's face sheet dated 08/28/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: paranoid schizophrenia (a disorder that affects the ability to think, feel and behave clearly), mild intellectual disabilities, cognitive communication deficit (inability to communicate effectively due to cognitive impairments), intermittent explosive disorder (a mental disorder characterized by explosive…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-20 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents, for 14 of 24 residents (Resident #12, Resident #31 and 12 confidential Residents), reviewed for resident rights. The facility failed to ensure staff performed rounds every two hours on the night shift. 12 of 12 residents who attended Resident Council stated CNAs do not perform rounds every 2 hours at night. Residents stated they have not had access to water due to the lack of rounding. Residents stated they have not had assistance with adjusting the temperature of their rooms and have not had assistance with turning due to the lack of rounding. The facility failed to ensure Resident #12 and #31 were rounded by night shif staff. This failure could place residents including at risk of not receiving…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-20 · tag F0565 — failed to support the resident council — pattern
    Honor 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 meeting space for residents' monthly council meetings for 12 of 24 confidential residents who were reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents at risk of not being able to voice concerns due to a lack of privacy. Findings include: Observation of dining room on 5/19/25 at 11:00AM revealed multiple staff in and out of the dining room, multiple residents in and out of the dining room who were not attending Resident Council, and several side conversations in the dining room due to Residents visiting family members in the dining room. Interview on 5/20/24 at 10:30AM, the Activities Director stated Resident Council was held in the dining room for the entirety of her employment with the facility, 18months. The AD stated it was not a private space; her sign posted during resident council asked staff not to enter the dining room was not respected. The AD stated there were no doors to close for 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-20 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to ensure the resident had a right to personal privacy and confidentiality of his or her personal and medical records which included accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups for 12 of 12 confidential residents. The facility failed to ensure staff were not on their personal cell phones while providing care, which included peri-care to residents. This failure could place residents at risk of not having their personal privacy maintained during medical treatment. Findings include: Interview with 12 confidential residents stated the use of cell phones by CNAs while performing care made them feel ignored, not a priority, embarrassed, concerned the CNA could make a mistake due to distraction by the cell phone conversation, and, most of all, their privacy was violated. Interview with 12 confidential residents stated the use of cell phones by CNAs occurred on every shift; however, primarily occurred during the night shift. Interviewed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-20 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 24 confidential residents. The facility failed to ensure 12 of 24 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information regarding who the facility grievance officer was, their contact information, and how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews during Resident Council on, 05/19/2025 at 11:00am, 12 confidential residents, stated they did not know they could file a Grievance anonymously and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council stated there was no system for submitting a Grievance anonymously. The 12 residents in attendance had all been Residents of the facility for…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-20 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 3 of 4 medication carts (medication cart for hall 200, medication cart for hall 100, and nurse's medication cart for hall 200), reviewed for medication storage. The facility failed on 05/19/25 to maintain proper medication storage after the following was found: 1. The medication cart for 200 hall contained 10.5 loose pills. 2. The medication cart for 100 hall contained 3 loose pills. 3. The nurse's medication cart for hall 200 contained 10 loose pills. This failure could place residents at risk of not receiving prescribed medications as ordered and place the facility at risk of drug diversions. The findings included: 1. On 05/19/25 at 9:03 AM an observation of the medication cart for 200 hall was conducted with MA A. Ten and one-half loose pills were found in the drawers of the medication cart. MA A placed the pills in a dispensing cup and took the cup to the DON for medication identification. The DON identified the medications as followed:…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Ecited before2025-05-20 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed on 05/18/2025 to seal and date food stored in refrigerator. The facility failed on 05/18/2025 to ensure kitchen equipment was clean. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 05/18/2025 at beginning 9:45 AM during initial tour of the kitchen: Observation of the following stored in dry storage room: 4 dessert cake pans with cake on rolling cart not covered. Large container of cornmeal with lid open. Observation of the following stored in the refrigerator: Bag of green beans with no date. Bag of corn with no date. Bag of spaghetti with meat sauce no date. Metal bowl of cooked beans with no date. Metal bowl of tartar sauce cups with no date. Observation of the Ice machine in dining room with cream color buildup in drip…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-20 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain 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 24 residents (Resident #73, #97 and #304) reviewed for infection control. 1. The facility failed on 05/18/25 to implement and maintain Enhanced Barrier Precautions physicians ordered on 04/16/25 when LVN B failed to wear proper PPE when providing wound care for Resident #97. 2. The facility failed on 05/19/25 to ensure proper medication administration infection control procedures were used when MA A failed to sanitize her hands before or after medication administration for Resident #73 and #304. These failures could place residents at risk for the spread of infection and cross contamination. Findings included: 1. Record review of Resident #97's face sheet dated 05/18/25 revealed a [AGE] year-old female with an admission…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-20 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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, interview and record review, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner and environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident individuality and protected and promoted the rights of the resident personal privacy for each resident's individuality for 1 of 24 residents (Resident #254) reviewed for dignity in that: The facility failed to ensure Resident #254's Condom catheter bag had a privacy cover on it to provide respect and dignity. This failure placed residents in the facility, with Condom catheters, at risk of feeling uncomfortable or embarrassed and decreased privacy. Findings included: Record review of Resident #254's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #254 diagnoses which included: Chronic kidney disease (a progressive condition where the kidneys gradually lose their ability to filter waste and excess…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-20 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 8.0% based on 2 errors out of 25 opportunities, which involved 2 of 3 residents (Resident #8 and Resident #304) reviewed for medication administration. 1. MA A failed to properly verify and dispense Eliquis (blood thinner) according to physician's order with a start date of 12/04/24 for Resident #304, when on 05/19/25 MA A dispensed and was going to administer Resident #304 with one 2.5 MG tablet instead of two 2.5 MG tablets until surveyor intervention. 2. MA A failed to administer Vitamin A (supplement) according to physician's order dated 05/13/25 to Resident #8, when on 05/19/25 MA A was unable to administer the Vitamin A supplement to Resident #8, resulting in a missed dose. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-20 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 24 residents (Resident #8) reviewed for dental services. The facility did not assist Resident #8, who had missing teeth, with a dental service consult. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. Findings included: Record review of Resident #8's face sheet showed a [AGE] year-old woman, who was admitted on [DATE]. Diagnoses included: Cerebral infarction (referred to as a stroke, means the death of brain muscle due to a reduced blood supply), Chronic obstructive pulmonary disease (a progressive lung disease that makes it hard to breathe), Constipation (problem with passing stool), Muscle weakness (a decrease in the strength and ability of muscles to perform their normal functions, often resulting in a reduced ability to move the body), Heart Failure (condition in which the heart does not pump…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-27 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 be free from abuse, neglect, misappropriation of property and exploitation for 1 of 3 residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's Morphine Medication. This failure could place residents at risk for not receiving prescribed medication. Findings include: Record review of Resident #1's, undated, face sheet revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dementia (loss of remembering), anxiety (feeling of uneasiness), dysphagia (swallowing difficulties), Cognitive communication deficit (difficulty communication) and chronic pain (long lasting pain). Record review of a Resident #1's quarterly MDS, dated [DATE], revealed a BIMS of 11, which indicated cognitively intact. Record review of Resident #1's physician orders, dated 02/25/25, revealed an active…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, 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 3 of 3 residents (Residents #1, #2 and #3) reviewed for infection control. 1. CNA A failed to utilize hand hygiene during incontinence care for Resident #1. 2. CNA B failed to utilize hand hygiene during incontinence care for Resident #2. 3. CNA C failed to utilize hand hygiene during incontinence care for Resident #3. These failures could place residents at risk for infection and cross contamination. Findings included: Resident #1 Record review of Resident #1's face sheet revealed an [AGE] year-old female originally admitted on [DATE]. Resident #1 had a medical history of cerebral infarction (lack of oxygen to brain due to clot), muscle weakness, and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS assessment dated [DATE], Section C-…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-04-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) The facility failed to protect foods from potential contamination. 2) The facility failed to ensure foods were not expired. These failures could place residents at risk for food contamination and foodborne illness. The findings included: - The following observation was made during a kitchen tour on 04/09/24 that began at 10:00 AM and concluded at 10:35 AM: -An opened bag of potato chips on the counter, open date 04/08/24. -An opened bag od bologna in the fridge, open date 04/05/24. -an opened gallon jug of milk in the fridge, best by 04/19/24. -an opened bag of shredded cheddar cheese in the fridge; open date 04/07/24. -an opened container of boiled eggs, best by 04/08/24. -2 stacks of small bowls stored right side up in the dish washing room. Interview on 04/10/24 at 2:49 PM, the Dietary Manager stated all the dietary staff were responsible for…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-12 · tag F0585 — failed to handle grievances — pattern
    Honor 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 observations, interviews and record review, the facility failed to make residents and residents' family members aware of the grievances process and allow them to exercise their right to file a grievance leading to the facility not addressing the grievances of residents. According to the facilities' grievance policy the facility failed to make prompt effortsto resolve grievances for 5 of 26residents. The facility failed to provide residents and family members follow up communication and resolutions to filed grievances. The facility failed to file and resolve a grievance for Resident #80 regarding missing laundry. The facility failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: During the survey process for the infection control task, it was determined that the laundry services staff members were not allowing residents enough time to locate lost clothing. Laundry was only holding lost clothing for 7-10 days and then placing the items in the hallway for anyone to reclaim. Observation of laundry services on…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-12 · tag F0645 — pattern
    PASARR 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 interview and record review, the facility failed to ensure preadmission screening for individuals identified with MI, DD, or ID were evaluated for services assessments 6 of 24 residents (Residents #2, #41, #71, #78, #83 and #292) reviewed for PASRR screening, in that: Residents #2, #41, #71, #78, #83 and #292 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of mental illness. These failures could place residents with an inaccurate PASRR Level 1 and no PASRR Level 2 Evaluation at risk for not receiving care and services to meet their needs. The findings included: Resident #2 Record review of Resident #2 electronic face sheet dated 04/10/2024 revealed an [AGE] year-old male admitted to the facility on [DATE]. The face sheet listed under Diagnoses Information, major depressive disorder. Record review of Resident #2's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of Dementia. Additionally, under Section C Cognitive Patterns, the MDS revealed 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-12 · tag F0770 — failed to provide lab services — pattern
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 #62) reviewed for labs in that: The facility failed to obtain Keppra level labs for Resident #62 as ordered by the physician. This failure could put residents who may have lab work ordered at risk of not having their medical needs met. Findings include: Record review of the admission record for Resident #62, dated 04/09/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include cerebral infarction (stroke), acute respiratory failure (lung problems), dysphagia (swallowing difficulties) and other seizures (sudden, uncontrolled burst of electrical activity in the brain). Record review of the comprehensive MDS for Resident #62, dated 11/10/23, reflected Resident #62 was understood and had a BIMS score of 07, which indicated his cognition was moderately impaired. The MDS further revealed Resident #62 had an active…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-12 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 Pureed) at 1 of 1 meal observed (04/10/24 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews 4 of 11 residents voiced concerns related to food palatability. One resident stated The food is not good. I do not like it. Another resident stated, The food is disgusting. I do not like it. I mainly eat the snacks they give. One other resident stated, The food is very salty. Another resident stated, The food is hard to eat because it is so salty. Record review of the Resident Council Minutes dated 10/26/23 revealed resident comments related to the food served in the facility. It was documented, cold…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-12 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 6 Residents observed for infection control for practices (Resident #3, #17, and #19) in that: 1. CNA A failed to wash hands prior to gathering perineal care supplies for Resident #3, CNA A failed to use proper hand washing during perineal care for Resident #3 while going from dirty to clean. CNA A failed to use correct hand washing practices after providing perineal care for Resident #3. 2. RN failed to use proper hand washing practices after providing wound care for Resident #17. 3. CNA B failed to use proper hand washing practices before and after providing perineal care for Resident #19. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included:…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-12 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that each resident has a right to personal privacy and confidentiality of his or her personal medical records for 1 of 1 resident reviewed on medication pass (Resident #88). a) The MA left two top halves of Resident #88's medication cards, with identifiable information, laying on the top of her medication cart unattended. This failure could place residents at risk of having medical information exposed to others and possible misuse of personal information. Findings Included: Record review of Resident #88's face sheet date retrieved on 04/11/2024, indicated Resident #88 was an [AGE] year-old female who was admitted on [DATE] with the following diagnoses: anxiety and pain. Record review of Resident #88's admission MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #88's Physician Orders dated 03/19/2024, revealed: Buspirone HCI Oral Tablet 10 mg, give one tablet…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial well-being for 3 of 24 residents (Residents #18, #38, and #78) reviewed for care plans. The facility failed to develop a care plan for Residents #18's current advanced directives. The facility failed to implement a care plan for Resident #38 for nutrition. The facility failed to implement a care plan for Resident #78 for falls. These failures could place residents at risk of not receiving the care required to meet their individualized needs. Findings include: Resident #18 Record review of the admission record for Resident #18, dated 04/09/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: Parkinson's disease (brain disorder), Alzheimer's disease (memory disorder), and essential hypertension (high blood pressure). Record review of Resident #18's comprehensive MDS…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-12 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in the cart for 1 of 4 medication carts (hall 200) in that: 1. MA was in the middle of medication pass when she realized she was missing a medication, she placed the already dispensed medications in an open medication cup and then placed them in her unlocked medication cart and then proceeded to the supply room to find the other medication. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions. The findings include: Observation of medication pass with MA on 04/11/2024 at 7:30 AM revealed MA was in the middle of medication pass with Surveyor for Resident #25, when she realized she was missing a medication (protonix), she placed the already dispensed medications (probiotic 1 capsule, aspirin 81 mg 1 tablet, atorvastatin 20 mg 1 tablet, amlodipine 5 mg 1 tablet, clopidogrel 75 mg 1 tablet, lisinopril 40 mg 1 tablet) in an open medication cup and then placed them in her unlocked medication cart 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-27 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 were free of any significant medication errors for 1 of 4 residents (Resident #1) reviewed for medication administration. The facility failed to ensure MA B administered Lorazepam 1mg tablet orally (to treat anxiety) to Resident #1 on 03/25/2024 according to physician orders. This failure could place residents at risk of receiving incorrect amounts of medication prescribed by their physician. Findings include: Record review of Resident #1's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's disease (memory loss), insomnia (difficulty sleeping), history of falls and anxiety disorder (feeling of fear or uneasiness). Record reviewed of Resident #1's admission MDS, dated [DATE], reflected in Section C, a BIMS score of 07 out of 15, which indicated her cognition was severely impaired. Record review of Resident #1's physician's orders, dated…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-11 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 1 of 5 residents (Residents #2) reviewed for care plans as follows: Facility failed to develop care plans for Resident #2's regarding hospice care, mechanical lift, weight loss, oxygen therapy and ADL's. These failures could place residents at risk of not receiving the care required to meet their individualized needs. Findings include: Resident #2 Record review of Resident #2's face sheet, dated 12/18/2023, revealed [AGE] year-old female admitted [DATE] with diagnoses that included, but were not limited to, acute on chronic diastolic (congestive) heart failure (heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly); hypothyroidism (under active thyroid- thyroid gland doesn't make enough thyroid hormone), type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PRIORITY MANAGEMENT — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.9+1.1 vs chain
Health inspection 4 of 53.2+0.8 vs chain
Staffing 1 of 51.6-0.6 vs chain
Quality measures 5 of 53.4+1.6 vs chain
The other 37 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Alpine Skilled Nursing and RehabilitationRuston, LA 1 of 5Bridgeport Medical LodgeBridgeport, TX 1 of 5Camelot Rehabilitation At Magnolia ParkLafayette, LA 1 of 5Colonial Oaks Skilled Nursing and RehabilitationBossier City, LA 1 of 5Hilltop Park Rehabilitation And Care CenterWeatherford, TX 1 of 5Pilgrim Manor Skilled Nursing and RehabilitationBossier City, LA 1 of 5Shreveport Manor Skilled Nursing & RehabilitationShreveport, LA 1 of 5St Joseph Skilled Nursing and RehabilitationMonroe, LA 1 of 5The Bradford Skilled Nursing And RehabilitationShreveport, LA 1 of 5The Guest House Skilled Nursing and RehabilitationShreveport, LA 2 of 5Booker T. Washington Skilled Nursing and RehabilitShreveport, LA 2 of 5Decatur Medical LodgeDecatur, TX 2 of 5Resthaven Living CenterBogalusa, LA 2 of 5Ridgmar Medical LodgeFort Worth, TX 3 of 5Broadmoor Medical LodgeRockwall, TX 3 of 5Camelot Of BroussardBroussard, LA 3 of 5Chateau St. James Rehab And RetirementLutcher, LA 3 of 5Louisiana Extended Care Hospital Of LafayetteLafayette, LA 3 of 5Mabank Nursing CenterMabank, TX 3 of 5Royse City Medical LodgeRoyse City, TX 3 of 5The Homestead of DenisonDenison, TX 3 of 5The Woodlands Healthcare CenterLeesville, LA 3 of 5Timber Springs Rehab and RetirementSpringhill, LA 4 of 5Belterra Health & RehabMcKinney, TX 4 of 5College Park Rehabilitation And Care CenterWeatherford, TX 4 of 5Jo Ellen Smith Convalescent CenterNew Orleans, LA 4 of 5Mansfield Medical LodgeMansfield, TX 4 of 5The Parks at Garland Healthcare and RehabGarland, TX 4 of 5Victoria Gardens Of AllenAllen, TX 4 of 5Victoria Gardens of FriscoFrisco, TX 4 of 5Vista Ridge Nursing & Rehabilitation CenterLewisville, TX 5 of 5Camelot BrooksideJennings, LA 5 of 5Chateau D'Ville Rehab and RetirementDonaldsonville, LA 5 of 5Chateau Terrebonne Health Care CenterHouma, LA 5 of 5Grapevine Medical LodgeGrapevine, TX 5 of 5Spring Lake Skilled Nursing And RehabilitationShreveport, LA 5 of 5Springtown Park Rehabilitation And Care CenterSpringtown, TX

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 / managerTypeRoleShareSince
FANNIN COUNTY HOSPITAL AUTHORITYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/01/2025
SANDERSON, CLARKIndividualCORPORATE DIRECTORsince 09/01/2025
PMG OPCO - LUBBOCK LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2025
BAUDER, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2025
BAUDER, KELLYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 09/10/2025
BAUDER, MADISONIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 09/10/2025
BAUDER, PARKERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 09/10/2025
BOULWARE, DOUGLASIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 09/10/2025
BOULWARE, SANDRAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 09/10/2025
BOULWARE, STEVENIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 09/10/2025
BOULWARE, THOMASIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 09/10/2025
WALKER, KATIEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 09/10/2025
BAUDER FAMILY INVESTMENTS, LLCOrganizationADP OF THE SNFsince 09/01/2025
BOULWARE ST JAMES LLCOrganizationADP OF THE SNFsince 09/01/2025
PMG REALCO-MABANK, LLCOrganizationADP OF THE SNFsince 09/01/2025
STEVEN BOULWARE FAMILY INVESTMENTS LLCOrganizationADP OF THE SNFsince 09/01/2025
SKINNER, DEREKIndividualADP OF THE SNFsince 09/01/2025
WHITESIDES, JESSICAIndividualADP OF THE SNFsince 09/01/2025

6 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.

$8.3M
Net patient revenuemost recent cost report
-13.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 64%Medicare 11%Other / private 25%

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

$282per resident / day
operating cost
$8,569per month
≈ monthly operating cost
$248per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676318. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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