Granite Mesa Health Center
1401 Max Copeland Dr, Marble Falls, TX 78654 · For profit - Limited Liability company · 124 certified beds · (830) 693-0022 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, F0602) — most recent Jan 2025
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $59,345 in federal fines (most recent 2025-01-27)
- 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 | 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 | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 30.8% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.8% | 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 | 0.3% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 4.5% | 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 | 10.4% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 17.4% | 14.0% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 13.5% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.7% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.3% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.7% | 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 | 99.4% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.2% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 26.6% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.21 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.13 | 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.
58.2% 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 138 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.8% 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 71 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 0.79 therapist hours per resident per day in 2026Q1 — more than 94% 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 | 58.2%CMS range 50.2–66.6 | 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 | 11.1%CMS range 8.5–14.3 | 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 | 71.8% | 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 | 73.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 64.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 1.1% | 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 | 1.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.1%CMS range 5.1–15.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.98 | 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 124 beds and averages 96.8 residents a day — about 78% occupied, or roughly 27 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.16 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 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 2.54 hrs/resident/day on weekends vs 3.42 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 0.46 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · J2025-01-27 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all residents were free from abuse for one (Resident #1) of four residents reviewed for abuse. The facility failed to keep Resident #1 safe from being yelled at, humiliated, and being denied care by CNA B. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/24/2025 at 5:42 PM . While the IJ was removed on 01/25/2025 at 2:45 PM, the facility remained out of compliance at a level 2 of no actual harm at a scope of isolated that was no immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of abuse, injury and psychosocial harm. Findings included: Review of Resident #1's face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of multiple sclerosis (a chronic autoimmune disease that affects the central nervous system, which includes the brain and spinal cord), muscle wasting and atrophy (loss of muscle…
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 · D2026-01-16 · 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
Based on observation, interview, and record review, the facility failed to ensure that each resident has the right to secure and confidential personal and clinical records for 1 of 34 residents (Resident #1) reviewed for Privacy and Confidentiality. The facility failed to ensure Resident #1's clinical records were protected from being viewed by unauthorized persons when CMA A left Resident #1's personal information visible on the computer's screen on unattended medication cart. This failure could place residents' personal information at risk of being exposed to unauthorized individuals. The findings included: Observation on 1/16/2026 at 9:42 a.m., revealed the computer screen on CMA A's medication cart on 400 Hall was open and unlocked, with Resident #1's medication administration information displayed and visible to unauthorized individuals, including visitors or other residents not observed at that time. During an interview on 1/16/2026 at 9:46 a.m. with CMA A, she stated she was in-serviced on HIPAA a few months ago which included instructions on not discussing residents' private…
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 · E2025-12-31 · 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 observation, interview, and record review, the facility failed to be ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relays relayed the call directly to a staff member or a centralized staff work area from each resident's bedside for 5 of 10 residents (Residents # 13, # 31, # 47, # 48 and # 67) reviewed for call lights.The facility failed to ensure Residents # 13, # 31, # 47, # 48 and # 67's call lights were within reach of the residents. These failures could place residents at risk of not being able to call for staff assistance to meet care needs or at risk of injury, pain, hospitalization, and a diminished quality of life.Findings included:1. Record review of Resident #13's face sheet, dated 12/30/2025, revealed she was a 68 -year-old female who was admitted to the facility on [DATE]. Resident #13's had diagnoses which included anxiety (feeling uneasiness or worry), dementia (memory, thinking, difficulty), Schizoaffective…
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 before2025-12-31 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 3 residents (Resident #1, Resident #26 and Resident #70) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #1's admission MDS, dated [DATE], accurately reflected his smoking status.2. The facility failed to ensure Resident #26's admission MDS, dated [DATE], accurately reflected her smoking status. 3. The facility failed to ensure Resident #70's admission MDS, dated [DATE], accurately reflected her smoking status.These failures could place residents at risk of inadequate supervision due to an inaccurate assessment of smoking status. Findings include:1. Record review of Resident #1's face sheet, dated 12/30/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included peripheral vascular disease (abnormal narrowing of arteries), adult failure to thrive (a progressive overall decline), localized…
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 · D2025-12-31 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a resident or family group with private space, and take responsible steps, with the approval of the group, to make residents and family members aware of upcoming meeting in a timely manner ensure the confidentiality offer Residents participating in Resident Council meetings in dining room [ROOM NUMBER] of 1 resident council meetings reviewed for resident rights.The facility failed to ensure that Staff members did not enter the dining room uninvited during the meeting, resident council meetings exposing residents to loss of privacy. This failure could affect place residents by placing them at risk for loss of privacy and dignity.The Findings included: Observation of the resident council meeting on 12/29/2024 at 2:30 PM, revealed that 2 staff members, (Hospitality Aide and Dietary Aide) entered the dining room entry doors during the resident council meeting. During an interview on 12/31/2025 at 9:08 AM, revealed that the Activities…
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 · D2025-12-31 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment were referred for 1 of 2 residents (Resident #4 and Resident #99) reviewed for PASSAR. The facility failed to ensure Resident #99's level 1 PASSAR accurately reflected her Mental Illness diagnosis.The facility failed to ensure Resident #4 received a new level 1 PASSAR screening after having a new diagnosis that would reflect a Mental Illness diagnosis.This failure could place residents at risk of loss of specialized services for their Mental Illness, Developmental Disability and Intellectual Disability. Findings include:Record review of Resident #4's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Bipolar Disorder (serious mental illness causing extreme mood swings, from…
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 · D2025-12-31 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 sufficient fluid intake is offered to maintain proper hydration and health provide hydration care and services to each resident, consistent with the resident's comprehensive assessment for 2 of 10 residents (Residents #10 and # 47) reviewed for hydration .The facility failed to follow the facility policy and did not provide adequate hydration for 2 residents. Residents #10 and #47. These failures could place residents at risk of not having hydration needs met and/or becoming dehydrated.Findings include: 1. Record review of Resident #10's face sheet, dated 12/31/2025, revealed a 92 -year-old female originally admitted on [DATE]. A Resident #10's relevant diagnoses included Alzheimer's Disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia.), Muscle wasting and atrophy, Muscle weakness, Anxiety Disorder (feeling of uneasiness or worry), Need…
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 · D2025-12-31 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food safety and Nutrition Services.The facility failed to ensure food safety by not performing proper hand hygiene when preparing puree foods.This failure could place residents at risk for food-borne illnesses.Findings include:Observation of DA A preparing puree food on 12/29/2025 at 10:29 a.m. revealed that DA A did not wash her hands before starting the puree process for the meatballs. She gave the puree machine to the dishwasher and went to wash her hands. She put meatballs into steamer. She then got a rag and wiped the counter down, got the puree machine. She put the noodles in the puree machine without washing her hands. She gave the puree machine back to dishwasher, got foil wrapped noodles put the noodles in the steamer, got water to add to steamer, and got a rag to wipe down the counter. She did not wash hands between any of the tasks she completed. She got 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 before2025-12-31 · 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 ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for complete and accurate medical records.The facility failed to ensure Resident #1's smoking assessments, dated 11/21/2025, accurately reflected his smoking status. Resident #1's smoking assessment said, resident don't smoke.This failure could place residents at risk of not having the right to smoke or not having adequate supervision while smoking. Findings include:Record review of Resident #1's face sheet, dated 12/30/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included peripheral vascular disease (abnormal narrowing of arteries), adult failure to thrive (a progressive overall decline), localized swelling, tinea unguium (fungal nail infection), muscle weakness, lack of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-30 · 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 ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 7 residents (Resident #1) reviewed for complete and accurate records. The facility failed to ensure Resident #1's medication and treatment was documented in PCC (electronic health records) for October 20th, November 13, November 14th, November 17th, November 18th, November 19th and November 20th. This failure could place residents at risk of not receiving care and services to meet their needs. Findings include:A record review of Resident #1's face sheet, dated 11/29/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included hypothyroidism (thyroid gland does not make enough thyroid hormones to meet the body needs), hemiplegia (paralysis that affects one side of the body), insomnia (difficulty falling on staying…
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 before2025-04-09 · 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 interviews and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for one (Resident #1) of three residents reviewed for respiratory care. The facility failed to ensure RN A documented Resident #1's response to oxygen therapy after she administered a nebulizer treatment on 04/03/25. This deficient practice could place residents that receive oxygen therapy at risk for inadequate care and respiratory distress. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), dysphagia (difficulty in swallowing), and muscle wasting and atrophy (wasting away). Review of Resident #1's admission MDS assessment, dated 03/06/25, reflected a BIMS was not conducted due to him rarely/never being understood. Section O (Special Treatments, Procedures, and Programs) reflected he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · F2024-10-02 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, observations, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 19 of 94 days reviewed for RN coverage. The facility failed to ensure they had an RN scheduled on duty for 19 days (07/04/2024, 07/08/2024, 07/09/2024, 07/14/2024, 07/22/2024, 08/05/2024, 08/19/2024, 08/30/2024, 09/03/2024, 09/04/2024, 09/10/2024, 09/16/2024, 09/17/2024, 09/18/2024, 09/24/2024, 09/25/2024, 09/26/2024, 10/01/2024, and 10/02/2024) and failed to ensure the DON was not acting as the charge nurse when the facility had an average daily occupancy of more than 60 residents. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: Review of the daily staffing for July 1, 2024, through October 2, 2024, reflected zero hours worked by an RN on the following days: -07/04/2024, -07/08/2024, -07/09/2024, -07/14/2024, -07/22/2024, -08/05/2024, -08/19/2024, -08/30/2024, -09/03/2024, -09/04/2024, -09/10/2024, -09/16/2024, -09/17/2024, -09/18/2024,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-02 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 ensure each resident was treated with respect, dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 4 (Resident #46, Resident #56, Resident #76, and Resident #78) of 18 residents reviewed for resident rights. The facility failed to ensure Resident #46 was changed after food was spilled on her clothes after meal service. This failure placed residents at risk for diminished quality of life and at risk for decreased feelings of self-worth and dignity. 1. Review of Resident #56's Face Sheet dated 10/02/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #56's diagnoses included heart failure, severe protein-calorie malnutrition, sleep apnea (breathing pauses while sleeping), hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), hyperlipidemia (high cholesterol), cardiac defibrillator (detects…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-02 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 4 (Resident #33, Resident #46 and Resident #69,and Resident #433 ) of 18 residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #33's quarterly MDS dated [DATE] accurately reflected her psychiatric/mood disorder. 2. The facility failed to ensure Resident #46's quarterly MDS date 07/21/2024 accurately reflected her psychiatric/mood disorder. 3. The facility failed to ensure Resident #69's quarterly MDS dated [DATE] accurately reflected his psychiatric/mood disorder. 4. The facility failed to ensure Resident #433's admission MDS dated [DATE] accurately reflected her psychiatric/mood disorder. This failure could result in inadequate care due to an inaccurate assessment of psychiatric and mood disorders. Findings include: 1. Review of Resident #33's face sheet dated 10/02/2024 revealed a [AGE] year-old female was admitted on [DATE] and had diagnoses of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-02 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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 an ongoing program of activities based on the comprehensive assessment, care plan and the preferences of each resident to meet the interests of and support the physical, mental, and psychosocial well-being for 2 of 5 (Resident #46 and #71) reviewed for activities . The facility failed to develop an ongoing activity program for Resident #46 and Resident #71. This failure placed residents at risk of not having their recreational and social needs met. Findings included: 1. Review of Resident #46's face sheet dated 10/02/2024 revealed a [AGE] year-old female admitted on [DATE] and had diagnoses of unspecified dementia (condition that causes a decline in cognitive abilities), Parkinson's disease (chronic brain disorder that causes movement problems), cognitive communication deficit (difficulty with communication cause by disruption to cognition) and major depressive disorder (serious mental disorder that affects how a person, feels,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-26 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect 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 each resident had the right to be free from misappropriation of property for 3 of 6 residents (Resident #1, Resident #2 and Resident #3) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Residents #1, #2, and #3's hydrocodone/APAP tablets (a schedule II controlled opioid medication used to treat pain). This failure placed residents at risk for not receiving prescribed medications. Findings included: 1. Record review of Resident #1's AR, dated 5/4/2022, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. She was diagnosed with Dementia (the loss of cognitive functioning), cognitive communication deficit (disorder that could cause trouble reasoning and making decisions while communicating) and muscle weakness. Record review of Resident #1's Quarterly MDS assessment, dated 09/16/2024, reflected based on Section C: Cognitive Patterns, the resident had no cognitive impairment.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-26 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure each resident had the right to be free from misappropriation of property for 3 of 6 residents (Resident #1, Resident #2 and Resident #3) reviewed for pharmacy services. The facility failed to follow their procedures that prevent drug diversions. This failure placed residents at risk for not receiving prescribed medications. Findings included: Record review of Resident #1's AR, dated 5/4/2022, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. She was diagnosed with Dementia (the loss of cognitive functioning), cognitive communication deficit (disorder that could cause trouble reasoning and making decisions while communicating) and muscle weakness. Record review of Resident #1's Quarterly MDS, dated [DATE], reflected Section C., Cognitive Patterns: Resident had no cognitive impairment. Section J: Health Condition; Resident received scheduled pain medication regimen. Section N., Medications: Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-16 · 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 a resident who was unable to conduct activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 1 of 6 residents reviewed for ADLs (Resident# 6) The facility did not provide Resident #6 clean sheets or gown when blood got on this sheet and gown. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings Included: Record review of Resident #6's face sheet dated 04/16/2024 revealed resident was admitted to the facility on [DATE]. Resident #6 was an [AGE] year-old male. His diagnoses included Dementia, protein-calorie malnutrition, difficulty with thinking and how someone uses language, heart failure, muscle wasting, edema, lack of coordination, iron deficiency anemia, high levels of fat particles in the blood, difficulty swallowing, high blood pressure, heart disease, reflux, altered mental status, long term use of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-16 · 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 residents who were unable to conduct activities of daily living received necessary services to maintain personal hygiene for 2 of 6 residents reviewed for ADLs. (Resident #3, and Resident #5) The facility did not provide scheduled showers for Resident #3. The facility did not assist Resident #5 close his gown causing him to expose his butt to the female across the hall from him on at least two occasions. This failure could place all residents who were dependent on staff for ADLs at risk for embarrassment, rashes, infections, discomfort, and skin break down. Findings Include: Record review of Resident #2's face sheet dated 04/16/2024 revealed Resident #2 was admitted to the facility on [DATE]. Resident #2 was a [AGE] year-old female. Her diagnoses included faster than normal heartbeat, diabetes, protein-calorie malnutrition, urinary tract infection, muscle wasting, lack of coordination, elevated levels of fat particles in the blood,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-02 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure they completed a PASRR evaluation on newly admitted residents prior to admission and after admission for one of three residents reviewed for PASRR screenings (Resident #50). The facility failed to ensure Resident #50's PASRR Level 1 screening indicated his was positive for mental illness. This failure placed residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. Findings included: Review of Resident #50's Face Sheet dated 08/02/2023 reflected a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses bipolar disorder (A serious mental illness characterized by extreme mood swings. They can include extreme excitement episodes or extreme depressive feelings.), and schizoaffective disorder, bipolar type (A mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder.) Review of Resident #50 Quarterly MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-02 · 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 residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of 15 residents (Resident #60 and #7) reviewed for quality of life. A) The facility failed to provide facial grooming and bathing assistance to Resident #60. B) The facility failed to ensure Resident#7's fingernails were trimmed and cleaned. These failures could place residents at risk for poor hygiene, dignity issues and decreased quality of life. Findings included: A) Review of Resident #60's undated face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, dysphagia (difficulty swallowing), anxiety disorder, hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Review of Resident #60's MDS assessment dated [DATE] reflected a BIMS score of 7, which indicated moderately impaired cognition. Review of Resident #60's 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 · D2023-08-02 · 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 residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for one three residents reviewed for catheters (Resident #7). The facility failed to ensure Resident #7's received care to prevent Urinary Tract Infections when they stored her catheter bag on the floor and did not ensure the catheter bag and tubing was positioned below the level of the bladder. These failures could place residents with foley catheters at risk for urinary tract infections and change of condition. Findings included: Review of Resident #7's Face Sheet dated 08/01/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Diabetes Mellitus Type II, Hypertension, and legal blindness. Review of Resident #7's admission MDS dated [DATE] reflected Resident #7 was assessed to not have a BIMS score assessment conducted indicating severe cognitive impairment.…
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 before2023-08-02 · 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 observation, interview and record review, the facility failed to ensure all residents received respiratory care consistent with professional standards of practice and resident preferences for one (Resident #41) of eight residents reviewed for respiratory care. The facility failed to ensure Resident #41 had an order for oxygen which should have specified the L/m required. The facility failed to ensure a licensed nurse adjusted Resident #41's oxygen. These failures placed Resident #41 at risk of respiratory distress. Findings included: A record review of Resident #41's face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of heart failure, Parkinson's disease (progressive disease of the nervous system), chronic respiratory failure, atrial fibrillation (irregular heartbeat), hypertension (high blood pressure), pneumonia, and major depressive disorder (depression). A record review of Resident #41's MDS assessment dated [DATE] reflected a BIMS score of 14, which reflected minimal…
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 · D2023-08-02 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days, except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, for two of five residents reviewed for unnecessary medications. (Residents #38 and #181) A) The facility failed to ensure a PRN order for Lorazepam (anti-anxiety) dated 07/07/2023 had a stop date to ensure the medication did not extend beyond 14 days for Resident #38. B) The facility failed to ensure a PRN order for Lorazepam (anti-anxiety) dated 07/27/2023 had a stop date to ensure the medication did not extend beyond 14 days for Resident #181. This deficient practice placed residents with PRN psychotropic drugs at risk for side effects of psychotropic drugs which include nausea, drowsiness, dizziness, confusion, constipation, diarrhea, and delirium and placed residents at risk for receiving unnecessary medications. Findings included: A) 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.
“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
$59,345 in federal fines across 1 penalty.
- $59,345 — penalty dated 2025-01-27
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 THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.2 | -1.2 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 1 of 5 | 2.7 | -1.7 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GUADALUPE COUNTY HOSPITAL BOARD | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/01/2017 |
| SYED, ASIF | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/11/2019 |
| THOMPSON, AMBER | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/27/2021 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | — | since 04/01/2017 |
| GANN, KODY | Individual | CORPORATE OFFICER | — | since 02/01/2021 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | — | since 03/01/2011 |
| COPELAND HEALTHCARE, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2017 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | — | since 05/01/2016 |
| NATIONAL HEALTH INVESTORS, INC. | Organization | ADP OF THE SNF | — | since 04/01/2017 |
| TEXAS NHI INVESTORS, LLC | Organization | ADP OF THE SNF | — | since 04/01/2017 |
CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $989K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 676220. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-31, 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.