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McAllen Nursing Center

600 N Cynthia St, McAllen, TX 78501 · For profit - Limited Liability company · 122 certified beds · (956) 631-2265 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited Apr 20252 immediate-jeopardy citations1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$17,459 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2025
  • 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
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • inspectors recorded 1 serious finding 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 (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $17,459 in federal fines (most recent 2024-10-28)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
901 East Hackberry Avenue
Pharmacy
300 S 2nd St Ste 101-A · (956) 365-2275 · Call to confirm hours
Grocery
401 E Cedar Ave · (956) 682-9475 · Call to confirm hours
Park
301 E Hackberry Ave · Typically dawn to dusk

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.3%15.8%15.4%better
Long-stay residents who lose too much weight1.7%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.6%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.4%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.3%3.3%3.3%better
Long-stay residents whose ability to walk worsened13.0%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.1%18.0%18.9%typical
Long-stay residents given the seasonal flu vaccine93.7%98.0%95.3%typical
Long-stay residents with pressure ulcers7.5%3.8%4.7%worse
Long-stay residents with worsening bladder/bowel control13.7%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table38.2%9.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication20.7%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine100.0%88.0%79.4%better

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.

0.52U.S. median 0.31
Therapy hours / resident / day
0.22hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.52 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

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

Staffing

0.31
RN hours/ resident / day
0.87
LPN hours/ resident / day
1.72
Aide hours/ resident / day
2.90
Total nurse hours/ resident / day
0.25
RN hoursweekends
40.7%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 122 beds and averages 69.8 residents a day — about 57% occupied, or roughly 52 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.90 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.72 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 2.60 hrs/resident/day on weekends vs 3.02 on weekdays — 14% thinner on weekends. RN hours go from 0.34 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% 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

6
deficiencies at the latest standard inspection (2025-04-24)
12
at the previous standard inspection (2024-02-29)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-10-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure adequate supervision was provided for 1 of 6 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident#1 received adequate supervision to prevent elopement. Resident #1 eloped from the facility and was found by the police department approximately 0.2 miles away from the facility. The Immediate Jeopardy template was provided to the facility on [DATE] at 4:38 p.m. While the Immediate Jeopardy was removed on 10/26/2024 at 1:33 p.m., the facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm because all staff was not aware of and did not implement the facility's elopement procedures. This failure could prevent residents from receiving appropriate supervision which could lead to resident sustaining serious injury, harm, or death. Findings included: Record review of Resident #1's electronic facility face sheet dated 10/24/2024,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2024-07-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 5 residents (R #1) reviewed for supervision. The facility failed to ensure R #1 received adequate supervision as R #1 eloped from the facility without anyone's knowledge on 07/19/24 between 7:30-7:40 PM and was found at an apartment complex approximately 0.2 mile away. R #1 was exit seeking, had increased behaviors, and staff placed R #1 in his room and failed to request additional interventions or increased supervision. R #1 was out of the facility for approximately 30 minutes before the facility became aware that he had eloped. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 07/19/24 and ended on 07/22/24. The facility corrected the non-compliance before the investigation began. This failure could lead to residents exiting the facility unattended which could result in injuries, hospitalization, or death. The 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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Immediate jeopardy · Lcited before2023-08-29 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 3 of 6 halls and 1 of 1 dining rooms reviewed for environment, in that: The facility failed ensure that 3 of 11 rooms (room [ROOM NUMBER], 21 and 22) in Hall B, 4 of 12 rooms (room [ROOM NUMBER], 47, 48, and 49) in Hall E, 5 of 11 rooms (room [ROOM NUMBER], 54, 55, 57 and 59) in Hall F received repair and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior that was free of environmental hazards. An IJ was identified on 07/21/23. The IJ template was provided to the facility on [DATE] at 4:52pm. While the IJ was removed on 08/09/23, the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm because repair of damaged areas had not yet been completed. These failures could lead to residents living in an environment…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #19) of 13 residents reviewed for comprehensive care plans. The facility failed to include Resident #19's use of a foley catheter (a device that drains urine from your urinary bladder into a collection bag outside of your body) in her care plan. These failures could place residents at risk of not receiving adequate care for a foley catheter device which could potentially lead to infection and deterioration of health. The findings were: Record review of Resident #19's face sheet dated 06/23/26 revealed a [AGE] year-old female originally admitted to the facility on [DATE] and then a re-admission date of 06/17/26. Her diagnoses included…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-13 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to respect the residents' right to personal privacy and confidentiality, for 3 of 11 residents (Resident #1, Resident #4, and Resident #7) reviewed for personal privacy and confidentiality. The facility failed to provide personal privacy and confidentiality for Resident #1, Resident #4, and Resident #7 when the residents and their private space were recorded without the resident's or designated representative's consent; and the video was posted on social media on 05/10/26. This failure could place residents at risk of their right to privacy and confidentiality not being honored or respected. Findings included:1. Record review of Resident #1's face sheet, dated 05/13/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: Alzheimer's disease (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia), mood disorder due to physiological condition…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-03 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 that the comprehensive care plans were periodically reviewed and revised by a team of qualified persons after each assessment, including both the comprehensive and quarterly review assessments for 2 of 3 residents (Resident #1 and Resident #2) reviewed for care plans, in that:1. The facility failed to ensure Resident #1's care plan reflected an unwitnessed fall on 11/27/2025.2. The facility failed to ensure Resident #2's care plan reflected witnessed falls on 11/14/2025, 12/16/2025, and 12/30/2025.This failure could place residents at risk of not being provided the necessary care or services and not having personalized care plans updated to address their specific needs. The Findings included:1. Record review of Resident #1's face sheet dated 2/3/26 reflected Resident #1 was admitted on [DATE] with an original admission date of 7/3/24. Resident # 1 was an [AGE] year old with diagnosis of muscle weakness, reduced mobility, stiffness of unspecified…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-21 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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 observation, interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #1) of 3 residents reviewed for accuracy of records, in that:LVN A failed to document the administration of clonazepam and insulin on 10/11/25 and 10/17/25.LVN B failed to document the administration of clonazepam and insulin on 10/27/25 and 10/28/25. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care.The findings included:Record review of Resident #1's face sheet dated 11/21/25 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: Parkinson's disease (movement disorder of the nervous system), type 2 diabetes (high levels of sugar in blood), unspecified intellectual disabilities, autistic disorder (developmental condition that affects…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-17 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 (Resident #1 and Resident #2) of 4 residents reviewed for medical records accuracy, in that: The facility failed to provide any documentation in the Progress Notes for Resident #1 and Resident #2 for the resident-to-resident altercation on 07/13/2025. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. The findings included: 1.Record review of Resident #1's admission record dated 08/16/2025, revealed a [AGE] year-old male with an initial admission date of 08/30/2024 and a re-admission on [DATE]. Resident #1's diagnoses included cerebral infarction (stroke), paranoid personality disorder (a personality disorder characterized by paranoia, and a pervasive, long-standing suspiciousness and generalized mistrust 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-22 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure each resident and/ or their representative and the IDT were invited to attend/participate in the care plan meetings including both the comprehensive and quarterly review assessments for the resident for 2 of 6 residents (Resident #1 and Resident 2) reviewed for care plan timing and revision. The facility failed to ensure Resident #1 and Resident #2's care plan was revised to accurately reflect current smoking status. The facility failed to develop a care plan for Resident #2 to address his discharge plan. These failures could place the residents at risk of not receiving appropriate interventions and care to meet their needs as indicated on the comprehensive care plans. The findings included: Record review of Resident #1's face sheet dated 05/20/25 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: bipolar disorder (mental health condition with mood swings), type 2 diabetes…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-24 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 4 (B-hall and D/E-halls) medication carts reviewed for medication storage. 1. The facility failed to store 17 loose tablets/capsules in their appropriate blister packs in the medication cart for B-hall. 2. The facility failed to store 17 loose tablets/capsules in their appropriate blister packs in the medication cart for D/E-halls. These deficient practices could place residents at risk of losing medications leading to medication shortage. The findings included: An observation of the B-hall medication cart on 04/23/25 at 12:25 PM revealed 17 assorted tablets and capsules loose in the 2nd drawer from the top. The drawer contained blister packs of medications for residents living on the B-hall along with the loose medications. An observation of the D/E-hall medication…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-24 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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 interviews and record reviews, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #2 and Resident #11) of 6 residents reviewed for accuracy and completeness of clinical records. 1. The facility failed to ensure LVN A correctly documented Resident #2's blood pressure 59 times when she administered blood pressure altering medications (amiodarone, hydralazine, metoprolol, and midodrine) between 04/01/25 and 04/23/25. 2. The facility failed to ensure LVN I correctly documented Resident #2's blood pressure 10 times when she administered blood pressure altering medications (amiodarone, hydralazine, metoprolol, and midodrine) between 04/01/25 and 04/23/25. 3. The facility failed to ensure LVN D correctly documented Resident #2's blood pressure 4 times when she administered blood pressure altering medications (amiodarone, hydralazine, metoprolol, and midodrine) between…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriaton of resident property, and exploitation for two out of 10 residents (Resident #59 and Resident # 100) reviewed for abuse/neglect. The facility failed to ensure Resident #59 was free of abuse. Resident #59 was hit on the head twice by Resident #100 on 02/22/25. This failure could place residents at risk of serious injury or death. The findings include: 1.Record review of Resident #59's face sheet dated 04/23/2025 indicated a [AGE] year-old male who was initially admitted to the facility on [DATE]. Resident #59 had a diagnoses which included nontraumatic subdural hemorrhage (rare condition where a blood clot forms in the space between the brain and its outer lining) , dysphagia( difficulty swallowing), difficulty in walking, other lack of coordination, muscle weakness, cognitive communication deficit (problems in communicating in conversations) , dementia (loss…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-24 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries or unknown source and misappropriation of residents property, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Agency, in accordance with State Law through established procedures for 1 out of 10 residents (Resident #59 that occurred on 02/24/25 to the local law enforcement agency, for 1 of 10 residents (Resident #59 ) reviewed for reporting of abuse/neglect. The facility failed to report an incident involving Resident #100 and Resident #59 that occurred on 02/24/25 to the local law enforcement agency. This failure could place residents at risk for potential abuse. The findings include: 1.Record review of Resident #59's face sheet…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Dcited before2025-04-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, as well as describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 6 (Residents #42 and #53) residents reviewed for care plans. 1) The facility failed to ensure Resident #42 was weighed weekly as ordered by the physician. 2) The facility failed to ensure Resident #53 was weighed weekly as ordered by the physician. These failures could place residents at risk of unnoticed weight loss or weight gain resulting in exacerbation of symptoms and increased morbidity. The findings included: 1. Record review of Resident #42's face sheet, dated 04/22/25, revealed a [AGE] year-old male with an initial admission date of 09/09/24 and a current admission date of 12/04/24. Resident #42'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-24 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one of 16 residents (Resident #40) reviewed for infection control practices. 1. The facility failed to ensure the WCN wore proper PPE (gown) during wound care for Resident #40 who required enhanced barrier precautions. 2. The facility failed to ensure CNA E wore proper PPE (gown) during wound care for Resident #40 who required enhanced barrier precautions. 3. The facility failed to ensure the WCN performed hand hygiene after removing a glove during wound care for Resident #40. 4. The facility failed to ensure CNA E performed hand hygiene after removing a glove while assisting during wound care for Resident #40. These failures could place residents at risk for healthcare associated cross-contamination 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-26 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 5 residents (R #1) reviewed for care plans. The facility failed to ensure R #1's care plan reflected the use of the wander guard, the antibiotics R #1 received for ESBL (bacterial infection) in the urine, and falls he experienced on 07/01/24, 07/10/24 and 07/14/24. This failure could place residents at risk of not receiving the care and services as indicated in the comprehensive care plans. The findings included: Record review of R #1's face sheet dated 07/24/24 reflected an [AGE] year-old male, with an original admission date of 05/23/24. Diagnoses included type 2 diabetes, hepatic encephalopathy (brain dysfunction caused by liver dysfunction), mood disorder, unspecified psychosis, hypertension, dementia with other behavioral disturbance,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-29 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards or food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to ensure all food items were labeled and dated in refrigerator #1. 2. The facility failed to keep personal drinks out of refrigerator#1 3. The facility failed to ensure expired food in refrigerator #2 was discarded. These failures could place residents at risk of foodborne illnesses. The findings included: An observation of the kitchen on 02/26/2024 beginning at 10:15 a.m., revealed there was a plastic container with beans that was not labeled in refrigerator #1, a personal 4 fl. Oz. bottle of water and an open 2-liter plastic bottle belonging to staff in refrigerator #1, and 2 gallons of milk that were expired in refrigerator #2. In an interview on 02/26/2024 at 10:30 a.m., the Dietary Manager said she would immediately discard the 2 gallons of milk that were expired and the beans in the plastic container that was not labeled.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-29 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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 interview, and record review, the facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment for (Resident #5, Resident #279, Resident #3, and Resident # 275) of 15 rooms reviewed for water temperatures in that: The facility failed to ensure resident room hand sink's hot water was maintained at a comfortable temperature which was at least 100 degrees F. These failures could place residents at risk for living in an uncomfortable, and unhomelike environment which could cause a diminished quality of life. The findings included: Observations on 02/28/24 begining at 8:45 am accompanied by the Maintenance Supervisor revealed hand sinks in rooms had temperatures below 98 degrees. Room # 45 79.8 degrees F room [ROOM NUMBER] 78.4 degrees F room [ROOM NUMBER] 74.6 degrees F Room # 49 77.1 degrees F Room # 50 85.9 degrees F room [ROOM NUMBER] 69.0 degrees F Room # 58 70.3 degrees F Room # 54 67.6 degrees F room [ROOM NUMBER] 86.5 degrees F room [ROOM NUMBER] 86.5 degrees…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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 environment remained as free of accident hazards as is possible for one (women's shower room) of two shower rooms reviewed for accidents. The facility failed to maintain water temperatures at a safe temperature level in the women's shower room. This failure could place residents at risk of injuries and burns. Findings include: Observation on 02/28/24 at 9:00 am with Maintenance Supervisor and using the supervisor's thermometer revealed the women's shower in the B hall had hot water temperature that was 121.4 degrees F. Interview on 02/28/24 at 9:10 am with the Maintenance Supervisor revealed the women's shower was in the B hall. All the residents in the facility were housed in the E and F halls. The water heater in the B hall was also used by the C hall. Both B and C hall were currently empty and had no residents. The Maintenance Supervisor said since the B and C hall did not have any residents using the rooms or the hot water, the hot water in the women's shower room would not circulate and caused…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-29 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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 maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 4 residents (Resident #18) reviewed for accuracy of records. 1. The facility failed to accurately document on Resident #18's MAR, post dialysis weight on 02/27/24 at 3:30 p.m. 2. The facility failed to accurately document Resident #18's PEG site care on MAR, on 02/26/2024 10-6a shift. 3. The facility failed to accurately document Resident #18's anticoagulant monitoring on [DATE]/26/24 10-6a shift, 02/27/24 6a-2 shift, 02/27/24 2-10p shift, and 02/27/24 10-6a shift. 4. The facility failed to accurately document Resident #18's SpO2 saturation on [DATE]/26/24 10-6a shift, 02/27/24 6a-2 shift, 02/27/24 2-10p shift, and 02/27/24 10-6a shift. 5. The facility failed to accurately document Resident #18's pain on [DATE]/26/24 10-6a shift, 02/27/24 6a-2 shift, 02/27/24 2-10p shift, and 02/27/24 10-6a shift. 6. The…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-29 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish 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, 4 residents of 5 (Resident #1, Resident #2, Resident #20, and Resident # 226) observed for infection control issues in that: 1. The LVN C did not sanitize the blood pressure cuff between resident use for Resident #1, Resident #2, and Resident #20 when taking resident's blood pressure prior to administering their medications. 2. During incontinent care for Resident #226 on 2/29/24 at 3:33 PM by CNA I failed to use appropriate incontinent care cleaning procedures. This deficient practice could place residents at-risk for infection due to improper sanitizing of shared equipment and incontinent care practices. The findings were: 1. Record review of Resident # 1's face sheet, dated 2/29/24, revealed a [AGE] year-old female admitted…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 1 resident (Resident #177) of 12 residents reviewed for accommodation of needs. The facility staff did not provide Resident #177 with a call light that was within reach. This failure could place residents at risk for not having his/her needs met. Findings included: Review of Resident #177's admission Record dated 02/26/24 documented a [AGE] year-old female, on hospice, initially admitted on [DATE], readmitted on [DATE], with the diagnoses that included cerebral infarction (stroke), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), aphasia (a language disorder that affects a person's ability to communicate), tracheostomy (an incision in the windpipe…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete an initial comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity for 2 of 4 resident (Resident#14 and Resident # 275 ) reviewed for comprehensive MDS assessment timing. The facility failed to complete the admission MDS assessment within 14 days of admission for Resident #14 and Resident #275. This failure could place residents at risk for not having their needs met. The findings included: Record review of Resident #14's admission record dated 02/27/24 reflected she was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #14's diagnoses included alzheimer's disease (a common cause of dementia), mood disorder due to known physiological condition, delusional disorders (paranoia), major depressive disorder (feeling of sadness), anxiety disorder (symptoms of anxiety), insomnia (sleep disorder), and cognitive communication deficit. Record review of Resident #14's admission MDS…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-29 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #14) of 4 residents reviewed for care plans. Resident #14's care plans did not reflect she was administered the medication Keppra (anti-convulsant) for behaviors. This failure placed residents at risk of not having their needs met. The findings included: Record review of Resident #14's admission record dated 02/27/24 reflected she was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #14's diagnoses included alzheimer's disease (a common cause of dementia), mood disorder due to known physiological condition, delusional disorders (paranoia), major depressive disorder (feeling of sadness), anxiety 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided with professional standards of practice for 2 of 3 residents (Resident #299 and Resident #177) reviewed for oxygen in that: 1. Resident #299 oxygen concentrator displayed a red warning light indicating oxygen flow rate <0.5L/min, or concentration <73 %. 2. Resident #177's oxygen was administered at 4.5 Lpm instead of 5 Lpm via trach mask as ordered by physician. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased qualify of care. The findings included: Record review of Resident #299's face sheet dated 02/29/2024 reflected he was admitted on [DATE] with an original admission date of 12/01/2022. Resident #299's relevant diagnoses were chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily function), dementia, atrial fibrillation (an irregular, often rapid…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish a pain management program designed to help a resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain, to the extent possible, for 1 resident of 4 (Resident #9) observed for pain management issues in that: 1. LVN B did not assess the pain level for Resident #9, prior to administering the resident her PRN pain medication. 2. The facility failed to adequately treat and assess Resident #9's pain. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life. Findings included: Review of Resident #9's admission Record dated 02/27/24 documented a [AGE] year-old female, initially admitted on [DATE], readmitted on [DATE], with the diagnoses that included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-29 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Observation and interview revealed the facility failed to provide a safe and functional environment for residents, staff and the public in 2 of 4 hallways (A Hall and E Hall) observed for environmental conditions. 1. The facility failed to ensure the bathroom ceiling on A Hall was free of dark discoloration. 2. The facility failed to ensure the ceiling in E Hall was free from dark discoloration. These deficient practices could affect any resident's health and safety. The findings were: Observation on 02/26/24 at 11:43 a.m. revealed discoloration on the ceiling outside room [ROOM NUMBER]. Two circular light brownish-yellow discoloration approximately 8 12 in diameter. 8 smaller discolorations black in color were in the same area. A [NAME] smeared substance was over black discolorations on ceiling. 02/27/24 10:15 AM Observation of A Hall. Discoloration black in color on bathroom ceiling room [ROOM NUMBER]. In an interview on 02/29/24 at 05:38 p.m. ADON E stated the maintenance supervisor checks the ceilings…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-10 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 1 (Resident #38) of 24 residents reviewed for PASRR: The facility did not correctly identify Resident #38 on the PASRR Level One Screening Form as having mental illness on admission and did not submit a request to correct their negative screening. This failure could affect residents with a diagnosis of mental illness and could result in these residents not receiving needed PASRR services. The findings included: Record review of Resident #38's admission Record revealed Resident #38 was a [AGE] year-old female admitted to facility on 04/28/19 with primary diagnosis of other sequelae of other cerebrovascular disease (an inability to perceive, report, and orient to sensory events towards one side of space), Mood Disorder due to known physiological condition, unspecified…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-02-29 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 nurse staffing data was posted and readily accessible to residents and visitors with all required information for 2 (2/27/24, 2/28/24) of 3 days reviewed for nurse staffing information. The facility failed to ensure the daily staffing information was posted in a prominent location on 2/27/24 and 2/28/24 and failed to show the census on each form. 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 include; During a tour of the facility on 2/27/24 at 4:00 pm, Surveyor was unable to locate the daily staff form. In an interview on 2/27/24 at 4:10 pm the DON informed the Surveyor that the Facility Staffing Disclosure form was located in the hallway by the Administrator's office. The DON then proceeded to show the Surveyor that the form was on the hallway inside a basket attached to the wall. The form was observed to be in a binder tilted sideways in a basket in a clear sleeve. In an…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$17,459 in federal fines across 2 penalties.

  • $8,447 — penalty dated 2024-10-28
  • $9,012 — penalty dated 2024-07-26

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 ADVANCED HEALTHCARE SOLUTIONS — 28 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.9-0.9 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 2 of 52.0≈ chain avg
Quality measures 3 of 54.0-1.0 vs chain
The other 27 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Advanced Health & Rehab Center of GarlandGarland, TX 1 of 5Advanced Rehabilitation and Healthcare of AthensAthens, TX 1 of 5El Paso Health & Rehabilitation CenterEl Paso, TX 1 of 5Greenville Health & Rehabilitation CenterGreenville, TX 1 of 5Tomball Rehab & NursingTomball, TX 1 of 5Winfield Rehab & NursingCrockett, TX 2 of 5Advanced Rehabilitation & Healthcare of BurlesonBurleson, TX 2 of 5Balch Springs Nursing HomeBalch Springs, TX 2 of 5Henderson Health & Rehabilitation CenterHenderson, TX 2 of 5Heritage House at Paris Rehab & NursingParis, TX 3 of 5Clarksville Nursing CenterClarksville, TX 3 of 5Palo Pinto Nursing CenterMineral Wells, TX 3 of 5Prairie House Living CenterPlainview, TX 3 of 5Santa Fe Health & Rehabilitation CenterWeatherford, TX 3 of 5Sulphur Springs Health And RehabilitationSulphur Springs, TX 3 of 5The Renaissance At Kessler ParkDallas, TX 3 of 5Whitehall Rehab & NursingCrockett, TX 3 of 5Willow Rehab & NursingKilgore, TX 4 of 5Advanced Rehabilitation And Healthcare Of VernonVernon, TX 4 of 5Advanced Rehabilitation and Healthcare of WichitaWichita Falls, TX 4 of 5Crowell Nursing CenterCrowell, TX 4 of 5Mesquite Tree Nursing CenterMesquite, TX 4 of 5Whispering Oaks Rehab & NursingCuero, TX 5 of 5Advanced Rehabilitation And Healthcare Of BowieBowie, TX 5 of 5Clyde Nursing CenterClyde, TX 5 of 5Heritage House At Keller Rehab & NursingKeller, TX 5 of 5Seymour Rehabilitation And HealthcareSeymour, TX

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
HOOPER, GRADYIndividualCORPORATE OFFICERsince 02/29/2024
MCALLEN HC LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 02/29/2024
SCHEINER, ELIEZERIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/29/2024
SILBERSTEIN, ARIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/29/2024

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$4.1M
Net patient revenuemost recent cost report
-46.8%
Operating marginrevenue minus expenses
$310K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 83%Medicare 2%Other / private 15%

About 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $310K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$316per resident / day
operating cost
$9,591per month
≈ monthly operating cost
$215per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 455560. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-24, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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