Larkspur
201 S. John Redditt Drive, Lufkin, TX 75904 · For profit - Corporation · 120 certified beds · (936) 632-3346 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jan 2025
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $30,928 in federal fines (most recent 2024-06-25)
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 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 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.
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 | 4.4% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.4% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.7% | 0.8% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 7.2% | 2.4% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.9% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 3.9% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.4% | 18.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.7% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 7.1% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.6% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.2% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 33.2% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.2% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.53 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.44 | 2.06 | 1.80 | worse |
‡ 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.
60.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 138 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.1% 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 78 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 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 60.7%CMS range 53.0–69.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 7.4–14.8 | 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 | 55.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 39.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 41.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 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 | 0.9% | 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 | 8.0%CMS range 5.2–13.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.00 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 86.0 residents a day — about 72% occupied, or roughly 34 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.42 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.546 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.69 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 2.89 hrs/resident/day on weekends vs 3.64 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.64 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · J2024-06-25 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from sexual abuse for 2 of 15 residents (Resident #1 and Resident #2) reviewed for abuse. 1. The facility failed to prevent sexual abuse for Resident #1 witnessed by CNA A on 06/08/2024 at approximately 2:00 p.m. to be in her room covered with a sheet and lying in bed with the Floor Tech. 2. The facility failed to prevent sexual abuse for Resident #2 that reported to CNA B on 06/08/2024 at 2:15 p.m. that the Floor Tech approximately two weeks prior had touched her hip, rubbed his penis against her while clothed, and asked if she was interested while making sexual body gestures. The noncompliance was identified as PNC. The IJ began on 06/08/2024 and ended on 06/08/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for psychosocial harm, impaired quality of life in unsafe environment, and further abuse. Findings included: 1. Review of a face…
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.
- Immediate jeopardy · Jcited before2024-02-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide adequate supervision and assistance to prevent accidents for 1 of 7 residents reviewed for accidents/supervision (Resident #1). The facility failed to ensure Resident #1's wheelchair was locked during a transfer causing the resident to slide out of the wheelchair and fall. Resident #1 sustained an acute comminuted fracture (when a bone breaks into 3 or more pieces) of the right femur (bone above the knee). The noncompliance was identified as PNC. The Immediate Jeopardy began on 10/24/23 and ended on 10/26/23. The facility had corrected the noncompliance before the survey began. This failure could place all residents at risk of severe injuries or death. Findings included: Record review of Resident #1's face sheet dated 10/31/23 indicated she was a [AGE] year old female admitted to the facility 11/3/22, with diagnoses including Type 2 Diabetes with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes),…
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 before2026-06-10 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to 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 6 residents (Residents #34, #66 and #71) and 2 of 7 staff (CNA A and CNA B) reviewed for infection control. 1. The facility failed to ensure CNA A followed EBP and proper infection control measures when providing direct care and handling soiled linens for Resident #66 on 6/08/2026. 2. The facility failed to ensure EBP was initiated and followed for Residents #34 and #66 on 6/08/2026 and 6/09/2026. 3. The facility failed to ensure CNA B followed EBP when providing direct care to Resident #71 on 6/09/2026. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings include: 1. Record review of Resident #66's facility face sheet, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-10 · 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 residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident (Resident #52) reviewed for enteral nutrition. The facility failed to ensure staff followed facility policy to label the formula label with date, time and initials of nurse when formula bag was started. This failure could affect residents by placing them at risk of dehydration and weight loss. Findings include: Record review of the face sheet, dated 6/09/26, reflected Resident #52 was a [AGE] year-old male who initially admitted to the facility on [DATE]. His diagnoses include severe protein-calorie malnutrition, paraplegia and dysphagia (difficulty swallowing). Record review of the nursing home MDS assessment, dated 3/13/26, reflected Resident #52 had a BIMS score of 09, which indicated moderate cognitive impairment. Resident #52 required total assistance from staff with ADLs. Resident #52 received 51% or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-02 · 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 is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 1 of 8 residents reviewed for ADLs (Resident #2)The facility failed to ensure Resident #2 received timely incontinent care on 10/29/2025.This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs, which could result in poor care.Findings included:Record review of an admission Record for Resident #2 dated 10/29/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral infarction (stroke), type 2 diabetes, major depressive disorder (persistent sadness and loss of interest in doing things) and hypertension (high blood pressure).Record review of a Quarterly MDS Assessment for Resident #2 dated 9/1/2025 indicated she did not have any cognitive impairment with a BIMS score of 13.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-02 · 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 observations, interviews, and record reviews, the facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls for 1 of 7 residents (Resident #3) reviewed for pharmacy services.The facility failed to ensure a tube of diclofenac sodium topical gel 1% (primary use for pain relief) was not in the room of Resident #3 on 10/28/2025.This failure could place residents at risk for adverse effects and reduced therapeutic effects of medication.Findings included:Record review of an admission Record for Resident #3 dated 10/28/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of benign neoplasm of cerebral meninges (non-cancer tumor in the brain), rheumatoid arthritis (chronic disorder that affects the joints), and chronic kidney disease (loss of kidney function).Record review of an admission MDS Assessment for Resident #3 dated 9/15/2025 indicated she had moderate cognitive impairment with a BIMS score of 11. During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-02 · 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 observations, interviews, 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 7 residents (Resident #2) reviewed for infection control.The facility failed to ensure CNA C changed her gloves, washed or sanitized her hands, and placed clean items on dirty linens when providing care to Resident #2 on 10/29/2025.This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of an admission Record for Resident #2 dated 10/29/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral infarction (stroke), type 2 diabetes, major depressive disorder (persistent sadness and loss of interest in doing things), and hypertension (high blood pressure).Record…
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 before2025-04-23 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 2 of 6 residents reviewed for ADLs (Residents #23 and Resident #24) 1.The facility failed to clean/groom Resident #23's fingernails. Resident #23 had long fingernails that were about an inch in length with a yellow-brown substance underneath them on 4/21/2025 and 4/22/2025. 2.The facility failed to clean/groom Resident #24's fingernails that had a black substance underneath them on 4/21/2025 to 4/23/2025. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care. Findings included: 1. Record review of an admission Record for Resident #23 dated 4/22/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of parkinsonism (nervous system disorder that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 6 residents (Resident #32) reviewed for accidents/hazards. The facility failed to remove worn and damaged mechanical lift slings from service from 04/21/2025 through 04/23/2025. This failure could place residents at risk of a loss of quality of life due to injuries. Findings included: 1. Record review of a facility face sheet dated 4/21/2025 for Resident #32 indicated that she was a 65 -year-old female admitted to the facility on [DATE] with diagnoses including morbid obesity due to excessive calorie intake and essential hypertension (uncontrolled blood pressure). Record review of a Quarterly MDS assessment dated [DATE] for Resident #32 indicated that she had a BIMS score of 15, which indicated she was cognitively intact. She was dependent for all transfers and most ADLs. Record review of a comprehensive care plan dated 3/11/2025 for Resident #32…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-23 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 2 medication rooms (Bluebonnet) reviewed for pharmacy services. The facility failed to dispose of expired medications from the medication room for Bluebonnet on 4/22/2025 which included: *Resident #35 had a foil package of albuterol 0.083% (nebulized medication that helps with breathing) that expired February 2025. *Resident #24 had a box of albuterol 0.083% that expired February 2025. *Resident #191 had 1 box of ipratropium/albuterol 0.5 mg/3 mg (nebulized medication that helps with breathing) that expired October 2024 and 3 boxes of ipratropium/albuterol 0.5 mg/3 mg that expired February 2025. These failures could place residents at risk for adverse effects and reduced therapeutic effects of medication. 1. Record review of an admission Record for Resident #35 dated 4/22/2025 indicated she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-23 · 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 observations, interviews, and record reviews the facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls for 1 of 18 rooms (room [ROOM NUMBER]) reviewed for pharmacy services. The facility failed to ensure a syringe of normal saline 0.9% (a solution used to maintain hydration) and 1 syringe of heparin 500 units per 5 ml (blood thinner) was were not on a bedside table in an unoccupied room (room [ROOM NUMBER]) on 4/21/2025. These failures could place residents at risk for adverse effects and reduced therapeutic effects of medication. Findings include: During an observation on 4/21/25 at 9:21 AM, an unoccupied room (room [ROOM NUMBER]) had 1 syringe of Normal Saline 0.9% and 1 syringe of heparin 500 units per 5 ml lying on a side table. During an interview on 4/21/25 at 9:33 am, LVN E said that the resident in room [ROOM NUMBER] was discharged to the hospital last week. She said she had only worked on 300 hall for a short time and was not sure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-23 · 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 observations, interviews, 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 #20) and 1 of 5 staff (CNA D) reviewed for infection control. CNA D failed to wear appropriate PPE for contact isolation precautions when providing care to Resident #20 on 4/21/2025. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: Record review of Resident # 20's facility face sheet revealed Resident #20 was a [AGE] year-old female and admitted on [DATE] with diagnosis of memory deficit following cerebrovascular disease. Record review of Resident #20's Quarterly MDS assessment dated [DATE] revealed a BIMS of 13 indicating intact cognition and required supervision with activities of daily…
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 12 citations
- Potential for harm · Dcited before2025-01-07 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 misappropriation of resident property for 1 of 2 residents (Resident #1) reviewed for misappropriation. The facility failed to prevent misappropriation of property when CNA A took money via cash app from Resident #1 in the amount of $106.00 dollars. The noncompliance was identified as PNC. The noncompliance began on 05/10/2024 and ended on 05/10/2024. The facility had corrected the noncompliance before the survey began. This failure could affect residents by putting them at risk for not being able to meet financial needs and diminished quality of life. Findings included: Record review of Resident #1's electronic face sheet, dated 01/06/2025, indicated Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged from the facility to home on [DATE] with two additional shorts stays (the latest stay admitted [DATE] and discharged to home 10/03/2024). Resident #1 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-07 · 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 observations, interviews, 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 16 residents (Resident #2) reviewed for infection control. The facility failed to ensure CNA D and CNA E wore appropriate PPE for enhanced barrier precautions when providing catheter care to Resident #2 on 1/6/25. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings include: Record review of a facility face sheet dated 1/6/25 for Resident #2 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of myocardial infarction (heart attack). Record review of a 5-day MDS assessment dated [DATE] for Resident #2 indicated that she had a BIMS score of 13, which indicated that she had intact…
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 · F2024-03-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility failed to date six packages of white cake mix and two packages of gelatin mix that were in the dry storage area on 3/4/2024. The facility failed to ensure the DM and [NAME] wore a hairnet effectively to cover all of their hair on 3/5/2024. These failures could place residents at risk for food-borne illnesses. Findings included: During an observation on 3/4/2024 at 9:10 AM in the kitchen, the dry storage area had six packages of white cake mix and two packages of gelatin mix that were removed from the original box that was not dated. During an interview on 3/4/2024 at 9:30 AM, the DM said everyone that worked in the kitchen were responsible for dating and labeling items and staff were aware not to put anything up without dating and labeling. During an observation and interview on 3/5/2024 at 11:15 AM, the [NAME] was pureeing food for lunch and the DM was present in the kitchen assisting as needed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-06 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the resident and the resident's representatives the right to participate in the development and implementation of his or her person-centered plan of care for 1 of 6 residents (Resident #4) reviewed for care plans. The facility failed to invite and include the input of the resident responsible party as members of the interdisciplinary team after the completion of the comprehensive assessment for Resident #4. This failure could place the residents at risk for decreased quality of life and not having their needs met. Findings included: Record review of a facility face sheet dated 3/6/24 for Resident #4 indicated that she was a [AGE] year-old woman admitted to the facility on [DATE] with a diagnosis of dementia. Record review of a Quarterly MDS assessment dated [DATE] for Resident #4 indicated that she had a BIMS score of 5, which indicated that she had severe cognitive impairment. Record review of a Quarterly Care Plan Conference invitation letter…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-06 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 the right to be free from misappropriation of property for 1 of 4 residents reviewed for misappropriation of property. (Resident #124). The facility failed to prevent a diversion (misappropriation) of Resident #124's Zofran tablets (used to treat nausea and vomiting) a total of 4 tablets. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity. Findings included: Record review of a facility face sheet dated 3/6/24 for Resident #124 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of acute posthemorrhagic anemia (a condition that develops when you lose a large amount of blood quickly and it causes a low number of red blood cells or a low amount of hemoglobin in your red blood cells). Record review of a Comprehensive MDS assessment dated [DATE] indicated that Resident #124 had a BIMS score of 15 which indicated that she was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-06 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
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 assess each resident quarterly (every 3 months or 92 days) using the MDS (minimum data set) form specified by the state and approved by CMS (Centers for Medicare & Medicaid Services) for 1 of 6 residents (Resident # 271) reviewed for quarterly assessments. The facility failed to ensure Resident # 271 had a quarterly MDS assessment completed within 3 months or 92 days from the previous assessment that was completed on 07/26/2023. This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions. Findings included: Record review of a facility face sheet dated 3/06/2024 indicated Resident #271 was a [AGE] year-old male and admitted to the facility on [DATE] with a diagnosis of cervical disc disorder (disorder of the bones in the neck). Record review of the MDS assessment list indicated Resident #271 had an admission MDS assessment completed on 7/26/2023 however did not receive a quarterly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #63) reviewed for indwelling catheters. The facility failed to prevent Resident #63's urinary catheter drainage bag from touching the floor. These failures could place residents at risk for inappropriate placement of indwelling catheters, discomfort or injury, and urinary tract infections. Findings included: Record review of a facility face sheet dated 3/6/24 for Resident #63 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of essential hypertension (high blood pressure). Record review of a Comprehensive MDS Assessment for Resident #63 dated 1/8/24 reflected that he had a BIMS score of 7, which indicated that he had severe cognitive impairment. Section H indicated that he used a urinary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided care, consistent with professional standards of practices for 2 of 13 residents reviewed for respiratory care (Residents #7 and #122). 1.The facility failed to ensure Resident #7's nebulizer mask was changed per the facility's policy. 2.The facility failed to ensure Resident #122's humidifier bottle and tubing for the oxygen concentrator were changed per the facility's policy and Physician orders. These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress. Findings included: 1.Record review of a facility face sheet dated 3/6/24 for Resident #7 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of hemiplegia following cerebral infarction (weakness/paralysis due to 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 · Dcited before2024-03-06 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 1 of 12 months (January 2024) reviewed for pharmacy services. The facility failed to properly inventory drugs at time of disposal on 1/31/24. This failure could put residents at risk for misappropriation and drug diversion. Findings included: Record review of facility drug destruction records dated February 2023 through February 2024 revealed that on January 31, 2024, the attached pages were only signed by the consultant pharmacist and contained no witness signatures or initials. During an interview on 3/6/24 at 11:00 am, the DON said that she had only been in this position for a couple of months, and going forward she would ensure that correct policies and procedures were followed for drug destruction. She said that without following proper…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-06 · tag 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 observations, interviews, 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 #271) and 1 of 7 staff (CNA E) reviewed for infection control. CNA E failed to perform hand hygiene while performing incontinent care to Resident #271 on 03/05/2024. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of a facility face sheet dated 3/06/2024 indicated Resident #271 was a [AGE] year-old male and admitted to the facility on [DATE] with a diagnosis of cervical disc disorder (disorder of the bones in the neck). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #271 had a BIMS of 15 indicating intact cognition and was incontinent of urine and bowel requiring moderate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-06 · tag F0919 — failed to provide a working call system — isolatedMake 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 1 of 6 residents reviewed for call lights. (Resident #4). The facility failed to ensure Resident #4's emergency call light in the bathroom had a cord enabling it to be reachable from the floor. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings included: Record review of a facility face sheet dated 3/6/24 for Resident #4 indicated that she was a [AGE] year-old woman admitted to the facility on [DATE] with a diagnosis of dementia. Record review of a Quarterly MDS assessment dated [DATE] for Resident #4 indicated that she had a BIMS score of 5, which indicated that she had severe cognitive impairment. Section GG indicated that she required supervision assist with toileting. Record review of a comprehensive care plan 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.
- No harm found · C2026-06-10 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 3 of 3 days reviewed for 3 of 3 days reviewed (06/08/2026, 06/09/2026 and 06/10/2026) for nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 06/08/2026, 06/09/2026 and 06/10/2026.This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings included:During an observation on 06/08/2026 at 11:01 AM, the daily staff posting was not in or around the front entrance lobby accessible to all visitors or residents. The daily staff posting was dated 06/08/2026 and located in a case on a wall in front of the Therapy department and down the hallway leading to 500/600 and 700/800 hallways. The posting was not visible to residents or visitors traveling toward the 100/200 and 300/400 hallways.During an observation on 06/09/2026 at 3:33 PM, 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.
“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
$30,928 in federal fines across 2 penalties.
- $17,068 — penalty dated 2024-06-25
- $13,860 — penalty dated 2024-02-12
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 CANTEX CONTINUING CARE — 37 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.1 | -0.1 vs chain |
| Health inspection | 4 of 5 | 2.9 | +1.1 vs chain |
| Staffing | 1 of 5 | 1.9 | -0.9 vs chain |
| Quality measures | 4 of 5 | 4.3 | -0.3 vs chain |
The other 36 homes this chain runs (chain average 3.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| TYLER COUNTY HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/01/2023 |
| WILLIAMS, SONDRA | Individual | CORPORATE OFFICER | — | since 06/18/2007 |
| STONELEIGH HEALTH CARE CENTER LTD. CO | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/26/2025 |
| COTTON, TIMOTHY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/10/2025 |
| BARTON, JO ELLEN | Individual | ADP OF THE SNF | — | since 11/15/2023 |
| DELA CRUZ, KRISTOPHER | Individual | ADP OF THE SNF | — | since 02/01/2024 |
CMS files one row per role, so the 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675519. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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