Parkwood In The Pines
902 Hill Street, Lufkin, TX 75904 · Government - Hospital district · 140 certified beds · (936) 637-7215 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has abuse, neglect, or exploitation citations (F0600, F0607) — most recent Nov 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- 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 (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $21,473 in federal fines (most recent 2024-10-07)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.9% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.5% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 5.7% | 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 | 4.0% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 12.0% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 4.9% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.3% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 7.8% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.5% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.6% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.3% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.3% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.69 | 2.17 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.73 | 2.06 | 1.80 | typical |
‡ 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.
59.3% 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 87 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.7% 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 30 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 0.60 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 59.3%CMS range 50.2–68.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 7.1–14.8 | 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 | 56.7% | 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 | 40.0% | 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 | 53.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.9%CMS range 4.0–11.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.26 | 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 140 beds and averages 104.7 residents a day — about 75% occupied, or roughly 35 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 3.14 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.80 hrs/resident/day on weekends vs 3.28 on weekdays — 15% thinner on weekends. RN hours go from 0.24 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
32 citations, most serious first. The 13 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · J2023-10-20 · 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 and physical abuse for 2 of 9 residents (Resident #1 and Resident #3) reviewed for abuse. The facility failed to prevent sexual abuse for Resident #1 found crying in her room with Resident #2's hand under her brief in perineal area on 10/8/23. The facility failed to prevent physical abuse for Resident #3 that was hit in the face in his room by Resident #4 and sustained injuries to include a bloody nose, skin tear to left side of nose, and swelling to his left ear on 10/11/23. The noncompliance was identified as PNC. The IJ began on 10/08/2023 and ended on 10/12/2023. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for physical harm, psychosocial harm, impaired quality of life in unsafe environment, and further abuse. Findings included: Review of facility policy, titled Abuse and Neglect - Clinical Protocol, revised 10/15/2022,…
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 before2023-10-20 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 2 of 9 residents (Resident #1 and Resident #3) reviewed for abuse. The facility failed to implement policies and procedures to prevent sexual abuse for Resident #1 found crying in her room with Resident #2's hand under her brief in perineal area. The facility failed to implement policies and procedures to prevent physical abuse for Resident #3 that was hit in the face in his room by Resident #4 and sustained injuries to include a bloody nose, skin tear to left side of nose, and swelling to his left ear. The noncompliance was identified as PNC. The IJ began on 10/08/2023 and ended on 10/12/2023. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for physical harm, psychosocial harm, impaired quality of life in unsafe environment, and further abuse. 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.
- Actual harm · Gcited before2024-10-07 · 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 devices to prevent accidents for 1 of 8 residents reviewed for accidents/supervision. (Resident #1) The facility failed to ensure Resident #1 was transferred to her bed using a mechanical lift on 10/2/24, causing pain to her right leg. This failure could place residents at risk of severe injuries. Findings included: Record review of Resident #1's undated current admission record indicated that Resident #1 was a [AGE] year-old female admitted to the facility 12/16/21, with diagnoses including hemiplegia (describes severe or complete unilateral loss of strength or paralysis) and hemiparesis (refers to weakness in one leg, arm, or side of the face) following cerebral infarction (the most common form of stroke), dysphagia (difficulty swallowing), muscle wasting and atrophy (wasting or thinning of muscle mass), type 2 diabetes (condition that results from insufficient production of insulin causing…
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 before2026-04-21 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of medications for 3 of 6 medication carts (medication cart for halls 400, 500, and 600, nurse cart for odd room numbers on hall 100 and 200, and medication cart for hall 100 and 200) reviewed for pharmacy services.The facility failed to remove (1) bottle of expired aspirin 325 mg and (1) box of arginaid powder (medication used to aid in wound healing) and a plastic bag of a white powder without a date from the medication cart for halls 100 and 200 on 4/20/2026.The facility failed to remove (1) box of arginaid powder from the medication cart for halls 400, 500, and 600 on 4/20/2026.The facility failed to remove an expired insulin vial of Humulin R 100 units/ml from the nurse cart for odd room numbers on hall 100 and 200 on 4/20/2026.These failures could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-21 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety for facility's only kitchen reviewed for food storage. The facility did not ensure foods in the freezer and dry storage area were stored, labeled and dated when opened or removed from their original packaging or opened on 4/19/2026. This failure could place residents who received their meals from the kitchen at risk of food-borne illness.Findings included: During an observation in the facility kitchen on 04/19/26 at 9:50 AM, the dry storage area had the following:*a container labeled thickener, the lid was open and off center. *a plastic bag with yellow dry mix dated 4/18/26 but no label of contents.*a plastic bag with opened package labeled brown gravy mix with no open date or use by date.*a container of enchilada sauce with no open or use by date, half of contents missing and manufacturer's label of refrigerate after opening. During an observation in the facility kitchen on 04/19/26 at 10:00 a.m., the freezer had the following:* 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 · D2026-04-21 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
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 right to personal privacy for 1 of 6 residents reviewed for resident rights. (Resident #64)The facility failed to ensure Resident #64 was treated with dignity and respect when the Treatment Nurse failed to provide privacy during wound care on 4/21/26.This failure could place residents at risk for feeling disrespected, a decreased sense of self-worth, and depression. Findings included:Record review of a facility face sheet dated 4/19/26 for Resident #64 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing (recovery after a displaced fracture of the base of the neck of the left femur - which occurs when the upper part of the femur, just below the hip joint, breaks and the bone fragments are misaligned from their normal position).Record review of Resident #64's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident's right to a safe, clean, and comfortable environment for residents for 1 of 24 residents (Resident #27) observed for resident environment.The facility failed to ensure the floor in Resident #27's room did not have standing water and was without odors from 4/19/2026-4/21/2026.These failures could place residents at risk for an unsanitary environment.Findings included:Record review of an admission Record for Resident #27 dated 4/21/2026 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral infarction (stroke), malignant neoplasm of lung (lung cancer), major depressive disorder (persistent sadness or loss of interest in doing things), and dysphagia (difficulty swallowing).Record review of a Quarterly MDS Assessment for Resident #27 dated 3/11/2026 indicated he had severe impairment in thinking with a BIMS score of 5. He was dependent on staff to transfer from chair to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-21 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 1 of 6 residents (Resident #64) reviewed for quality of care.The facility failed to ensure Resident #64's surgical site was monitored for signs and symptoms of infection each shift while a non-removable dressing was in place from 4/9/26 to 4/20/26.This failure could place residents at risk of not receiving appropriate care and treatment and/or decline in their health.Findings include:Record review of a facility face sheet dated 4/19/26 for Resident #64 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing (recovery period after a displaced fracture of the base of the neck of the left femur - which occurs when the upper part of the femur, just below the hip joint, breaks and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-21 · 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
Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 1 facility (3 of 7 mechanical lift slings) reviewed for hazards:The facility failed to remove faded, worn and damaged mechanical lift slings from service. This failure could result in a loss of quality of life due to injuries. Findings included:During an interview and observation of the facility laundry on 04/20/2026 2:30 PM the Laundry Supervisor said she washed the lift slings and hung them up to air dry. Three of the seven mechanical lift slings hanging on the wall racks drying in the clean linen area had faded straps, light in color (light gray, light teal and light purple) not bright and vivid colors as the other mechanical lift slings hanging on the rack. One of the mechanical lift slings care label was faded and attached by a few threads of stitching. The Laundry Supervisor said she had new mechanical lift slings and would replace the 3 damaged lift slings. She said she considered the three lift slings still…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-21 · 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 observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent infections and to restore continence to the extent possible for 1 of 5 (Resident #7) residents observed for urinary catheter (tube placed in the bladder that drains into a bag outside of the body) care.LVN D did not provide appropriate catheter care for Resident #7 when she did not use the proper cleaning agent or clean the catheter tubing on 4/21/2026.This failure could place residents at risk for bacterial infections from improper catheter care. Findings include:Record review of an admission Record for Resident #7 dated 4/21/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia (paralyzed on one side of the body), COPD (a group of lung diseases that affect breathing), type 2 diabetes, and chronic kidney disease (a condition where the kidneys are damaged).Record review of 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 before2026-04-21 · 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 2 of 6 staff (CNA C and LVN D) and 2 of 5 resident (Resident #5 and Resident #7) reviewed for infection control.1.The facility failed to ensure CNA C washed or sanitized her hands between glove changes and did not touch clean items with dirty gloves when incontinent care was provided to Resident #5 on 4/19/2026.2.The facility failed to ensure LVN D washed or sanitized her hands between gloves changes during urinary catheter care to Resident #7 on 4/21/2026These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:1. Record review of an admission Record for Resident #5 dated 4/19/2026 indicated she admitted to the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-21 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 dining area reviewed for environmental concerns. 1. The facility failed to ensure the dining room ceiling was in good repair and without damage and peeling paint. 2. The facility failed to ensure the dining room lighting and ceiling were free from thick cobwebs and dust. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.Findings include: During observations on 04/19/26 at 12:00 PM revealed the following:*thick cobwebs and dust were noted to the chandelier and extending to the ceiling in the center of the main dining area located above resident dining tables. an area of loose peeling paint was noted to the ceiling located between center island area of the main dining room and resident dining table. During an interview on 04/21/2026 at 10:30 AM, the Housekeeping Supervisor said she was unsure of who…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-18 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 6 residents (Residents #1) reviewed for medical records.The facility failed to ensure Resident #1's physician's orders were updated to include the resident was a DNR status and was uploaded in his medical record.This deficient practice could place residents at risk of improper care due to inaccurate medical records.The findings include:Record review of Resident #1's admission Record, dated [DATE], indicated a [AGE] year-old male who admitted to the facility on [DATE] and expired [DATE]. Resident #1 had diagnoses which included malignant neoplasm of colon (colon cancer), hypertensive heart disease (damaged heart muscle due to high blood pressure), anemia (not enough healthy red blood cells in the body) and infection of amputation stump, right lower extremity (infection in the right lower leg…
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 19 citations
- Potential for harm · Ecited before2025-02-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 4 of 12 residents (Residents #75, #61, #58 and #79) reviewed for accidents/hazards. The facility failed to remove worn and damaged mechanical lift slings from service from 2/10/2025-2/12/2025. This deficient practice could place residents at risk of a loss of quality of life due to injuries. Findings included: 1. Record review of an admission Record dated 2/11/2025 for Resident #75 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of fracture of left femur (broken thigh bone), osteoporosis (brittle bones), and Alzheimer's disease. Record review of active physician orders dated 2/11/2025 for Resident #75 indicated there was not an order for the use of a mechanical lift for transfers. Record review of a Quarterly MDS assessment dated [DATE] for Resident #75 indicated she had moderate impairment in thinking with 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 · E2025-02-12 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals were store in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 3 of 12 residents (Resident #17, #18 and # 86) reviewed for medication storage. 1.The facility failed to ensure Total Beets soft chews was not stored at the bedside of Resident #17 on 2/10/25 . 2. The facility failed to ensure a bottle of OTC (over the counter) throat spray was not stored at the bedside of Resident #18 on 2/10/25. 3. The facility failed to ensure aspercreme with lidocaine and nasal spray was not stored at the bedside of Resident #86 from 2/10/2025-2/11/2025. These failures could place residents at risk for adverse effects and reduced therapeutic effects of medication and supplies. Findings include: 1.Record review of a face sheet indicated that Resident #17 was an [AGE] year-old female admitted to the facility on [DATE]. Diagnosis includes osteoarthritis (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 before2025-02-12 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 4 residents (Resident #39) reviewed for resident rights. The facility failed to ensure Resident #39's Responsible Party was notified after she experienced pain in her right leg and had an X-ray ordered. This failure could place residents at risk of not being informed of illness, injury, and uncontrolled pain. Findings included: Record review of a facility face sheet dated 2/10/25 for Resident #39 indicated that she was an [AGE] year-old female admitted to the facility 12/16/21 with diagnoses including Alzheimer's disease and type 2 diabetes mellitus. Record review of a Comprehensive MDS assessment dated [DATE] for Resident #39 indicated that she had a BIMS score of 4, which indicated that she 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 · D2025-02-12 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 complete a significant change MDS assessment within 14 days after a significant change in the resident's mental and physical condition for 1 of 6 residents (Resident #82) reviewed for assessments. The facility failed to reassess Resident #82 following a hospice admission (specific care for the sick or terminally ill) on 12/17/2024. This failure could place residents at risk for not having their individual needs met due to inaccurate assessments. The findings included: Record review of an admission Record for Resident #82 dated 2/11/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of atherosclerotic heart disease (hardened arteries that prevent blood flow), hypertension, and Alzheimer's disease. Record review of active physician orders dated 2/11/2025 for Resident #82 indicated an order to admit to hospice services with an order date of 12/17/2024. Record review of a Quarterly MDS Assessment for Resident #82…
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 before2025-02-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 1 of 6 residents (Resident #6) reviewed for ADL care. The facility failed to ensure Resident #6 had nail care done on 2/12/25 and 2/13/25. This failure could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity. Findings included: Record review of a facility face sheet dated 2/10/25 indicated that Resident #6 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Dementia, epilepsy (seizures), and diabetes mellitus. Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated he had a BIMS score of 9, which indicated he had moderate cognitive impairment. He required moderate assistance with all ADL's. Record review of a comprehensive care plan dated 8/8/24 for Resident #6…
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 before2025-02-12 · 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 4 months (July 2024) reviewed for pharmacy services. The facility failed to document the number of pages that were included and did not have the required witness signatures for drug destruction on 7/12/2024. This failure could put residents at risk for misappropriation and drug diversion. Findings included: Record review of facility drug destruction records for four of the 12 months (April 2024, July 2024, September 2024, and December 2024) reflected that on 7/12/2024 the cover page did not indicate the number of pages that were included, and the attached pages were only signed by the DON and did not include any additional witness signatures. During an interview on 2/12/2025 at 10:00 AM, the DON said the drug destruction sheets were normally…
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 before2025-02-12 · 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 #62) and1 of 5 staff (CNA D) reviewed for infection control. The facility failed to ensure CNA D washed their hands before providing incontinent care to Resident #62 on 2/11/25. The facility failed to ensure CNA D appropriately changed gloves and washed hands while providing incontinent care to Resident #62 on 2/11/15. The facility failed to ensure CNA D properly cleaned the penis of Resident #62 while providing incontinent care on 2/11/25. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: Record review of a facility face sheet dated 2/11/25 for Resident #62 indicated that he was an [AGE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-01-10 · 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 observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation in that: During the initial observation on in the kitchen the low temperature, chemical sanitation dish machine, did not reach the manufacturer's recommended minimal water temperature of 120 degrees Fahrenheit, (F) during the final rinse cycle This failure could place the residents at risk of foodborne illnesses. Findings included: During an observation and interview 01/08/24 beginning at 9:15 a.m., DA-N was standing at the dish machine washing the breakfast dishes, he said he had worked at the facility for two years. He said he was trained to test the machine by the DM. Upon request the DA-N tested the dish machine, and it tested at 50 parts-per-million, (PPM), of hypochlorite (chlorine), and the water temperature read 111 degrees Fahrenheit, (F). DA-N ran the machine five times to try to get the water temperature up to required 120 degrees Fahrenheit, (F). On the fourth time the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 12 residents (Resident #286) reviewed for resident rights. CNA C and CNA D failed to provide privacy to Resident #286 when providing incontinent care on 01/09/2024 . This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety. Findings: Record review of a facility face sheet for Resident #286 revealed Resident #286 was admitted on [DATE] with diagnosis of muscle wasting and atrophy (weakness and breakdown of muscles). Record review of an admission MDS assessment dated [DATE] revealed Resident #286 had a BIMS of 04 indicating severely impaired cognition and required maximal assistance with toileting hygiene. Record review of a comprehensive care plan dated 12/07/2023 revealed Resident #286 had an ADL self-care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-10 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 immediately inform the resident's responsible party when there was an accident involving the resident which resulted in injury or had the potential for requiring physician intervention for 1 of 5 residents (Resident #18) reviewed for notification of change of condition. The facility failed to notify Resident #18's responsible party when Resident #18 sustained an unwitnessed fall on 12/29/2023 on or about 3:30 AM in her room when she slid out of bed to the floor. This failure placed residents' caregivers at risk of not being aware of any changes in their conditions and could result in a delay in treatment and decline in residents' health and well-being. Findings included: Record review of an admission Record for Resident #18 dated 1/9/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of senile degeneration of brain (mental deterioration or loss of thinking ability with old age), psychotic disorder…
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 before2024-01-10 · 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 observation, interview, 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 for 1 of 6 residents (Resident #57) reviewed for appropriate treatment and services to prevent urinary tract infections (an infection in any part of the urinary system, the kidneys, bladder, or urethra (is a hollow tube that lets urine leave your body) and quality of care. The facility failed to ensure Residents #57's indwelling catheter (drains urine from your bladder into a bag outside your body) was secure and stabilized on 01/09/2023. This failure could place residents at risk for urinary tract infections and catheter related injuries. Findings: Record review of facility face sheet dated 01/10/2024 revealed Resident #57 was a [AGE] year-old male that admitted on [DATE] with diagnosis of chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-10 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 (Resident #43) residents reviewed for intravenous fluids. The facility failed to ensure Resident #43 received PICC (a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) line dressing changes with a dressing dated 12/28/2023 This failure could affect residents by placing them at risk for infection. Findings included: Record review of an admission Record dated 1/10/2024 for Resident #43 indicated he admitted to the facility on [DATE] with a recent admission date of 12/31/2023 and was [AGE] years old with diagnoses of hemiplegia and hemiparesis (paralyzed on one side of the body), diabetes and osteomyelitis (infection in the bone). Record review of a Quarterly MDS Assessment for Resident #43 dated 12/4/2023 indicated he had severe impairment in thinking with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-10 · 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 reviews, 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 2 of 6 residents (Resident # 25 and Resident #286) reviewed for infection control. The treatment nurse failed to perform proper hand hygiene while providing wound care to Resident #25 on 01/10/2024. CNA C failed to perform proper hand hygiene while providing incontinent care to Resident #286 on 01/09/2024. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of a facility face sheet for Resident #25 revealed Resident #25 was readmitted on [DATE] with diagnosis of dysphagia (difficulty swallowing). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #25 had a BIMS of 06 indicating severely impaired cognition,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-22 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure 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 3 of 7 residents (Residents #1, #2, and #3) reviewed for call lights. The facility failed to ensure Residents #1, #2, and #3's call light was accessible and in reach. Resident #1's call light was attached to the privacy curtain at the foot of the bed, Resident #2's call light was hanging on the floor at the end of the bed, and Resident #3's call light was wrapped around the assist bar and hanging off the side of the bed. These failures could affect residents who used their call light or desire to use the call light and place them at risk of not being able to notify staff of their needs. Findings: Record review of the face sheet dated 11/21/2023 indicated Resident #1 admitted to the facility on [DATE] and readmitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-22 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for 1 of 7 residents (Resident # 1) reviewed for dignity. The facility failed to ensure Resident # 1's urinary drainage bag had a dignity/privacy cover. This failure could place residents in the facility at risk for a diminished quality of life, loss of dignity and self-worth. Findings: Record review of the face sheet dated 11/21/2023 indicated Resident #1 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of dysphagia (difficulty swallowing), urinary tract infection (infection of the bladder), cerebral infarction (impaired blood to brain causing damage), and malnutrition (lack of sufficient nutrients in the body). Record review of the admission MDS dated [DATE] indicated Resident #1 had a BIMS of 08 indicating moderately impaired cognition and required extensive assistance with all ADL's . Record review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-22 · 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 provide the necessary services to maintain personal hygiene for 1 of 7 residents (Resident #1) reviewed for ADL's. The facility failed to ensure Resident #1's face, mouth and nails were kept clean. 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, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings: Record review of the face sheet dated 11/21/2023 indicated Resident #1 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of dysphagia (difficulty swallowing), urinary tract infection (infection of the bladder), cerebral infarction (impaired blood to brain causing damage), and malnutrition (lack of sufficient nutrients in the body). Record review of the admission MDS dated [DATE] indicated Resident #1 had a BIMS of 08 indicating moderately impaired cognition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-10 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect of residents for 1 of 4 residents (Resident #1) reviewed for neglect. The facility failed to implement their Abuse policy and ensure all allegations that resulted in serious bodily injury were reported to HHSC within 2 hours of the allegation for Resident #1 who had a fall on 10/21/2023 at 4:53 AM. This failure could place residents at risk of being neglected and lack of oversight by a state agency. Findings included: Record review of a facility policy titled Abuse Investigation and Reporting with a revised date of October 15, 2022, indicated, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Reporting: 2. An alleged violation of abuse, neglect, exploitation, 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 · D2023-11-10 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily for 1 of 4 residents (Resident #1) reviewed for neglect. The facility did not report to the state agency within 2 hours when an allegation of neglect occurred on 10/21/2023 that involved Resident #1 who had a fall and sustained a small cut to her left ear and two brain bleeds. This failure could place vulnerable residents at risk of harm due to delays in reporting an allegation of neglect. Findings included: Record review of a face sheet for Resident #1 dated 11/8/2023 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of unspecified glaucoma (eye disease that causes…
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 · C2026-04-21 · 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 1 of 3 days reviewed (4/19/26) for nurse staffing posting.The facility failed to post the daily staffing information in a prominent place on 4/19/26. 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 4/19/26 at 9:30 am upon entrance to the facility, the daily staff posting was not observed in the main entrance lobby.During an observation on 4/19/26 at 10:00 am during initial rounds of the facility, the daily staff posting was not observed at or near the nurse's station for 400/500/600 hallways.During an observation on 04/19/2026 at 3:30 pm the daily staff posting was observed posted at each side of the facility near both nurses' stations. Posting was located on a short, side hall near staff offices. It was not in a prominent location.…
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
$21,473 in federal fines across 2 penalties.
- $8,824 — penalty dated 2024-10-07
- $12,649 — penalty dated 2023-10-20
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CITY OF ENNIS | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/16/2021 |
| NELSON, MARTY | Individual | CORPORATE DIRECTOR | — | since 12/16/2021 |
| PMG OPCO - LUFKIN LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/16/2021 |
| BAUDER, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/16/2021 |
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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 455673. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-21, 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.