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Belterra Health & Rehab

2170 North Lake Forest Drive, McKinney, TX 75071 · Government - Hospital district · 103 certified beds · (972) 542-5500 Medicare & Medicaid certified

Call the home — (972) 542-5500 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 20 lower-level deficiencies on record (see below)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1872 N Lake Forest Dr · (972) 548-0758 · Call to confirm hours
Pharmacy
5236 W University Dr Ste 1900 · (469) 764-7100 · Call to confirm hours
Grocery
Kroger0.6 mi
1801 N Lake Forest Dr · (469) 678-3881 · Call to confirm hours
Park
3050 Virginia Pkwy · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 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 rating5★
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 increased7.9%15.8%15.4%better
Long-stay residents who lose too much weight5.4%3.0%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.7%0.8%2.0%typical for the state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms9.4%2.4%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.6%3.3%3.3%typical
Long-stay residents whose ability to walk worsened10.9%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication21.2%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine98.6%98.0%95.3%typical
Long-stay residents with pressure ulcers2.2%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control11.7%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table1.9%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine98.3%88.0%79.4%better
Short-stay residents rehospitalized after admission24.4%25.7%22.6%typical
Short-stay residents with an outpatient ER visit8.8%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days2.022.171.67worse
Long-stay outpatient ER visits per 1,000 resident days1.042.061.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

46.2% 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 171 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.2%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
53.9%U.S. median 56.6%
Met the expected recovery
0.96U.S. median 0.31
Therapy hours / resident / day
0.42hours / resident / day
Physical therapy
0.42hours / resident / day
Occupational therapy
0.12hours / resident / day
Speech therapy

Met the expected recovery: 53.9% 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 115 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 0.96 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF46.2%CMS range 38.4–55.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 8.7–14.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge53.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge56.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge35.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.8%CMS range 3.6–8.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.521.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.80
RN hours/ resident / day
0.61
LPN hours/ resident / day
1.98
Aide hours/ resident / day
3.39
Total nurse hours/ resident / day
0.76
RN hoursweekends
36.7%
Total nursing turnover
35.3%
RN turnover

How full it usually is: this home is certified for 103 beds and averages 91.1 residents a day — about 88% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.07 hrs/resident/day on weekends vs 3.52 on weekdays — 13% thinner on weekends. RN hours go from 0.82 to 0.76 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% 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

10
deficiencies at the latest standard inspection (2026-04-23)
5
at the previous standard inspection (2025-02-13)

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.

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.

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

  • Potential for harm · E2026-04-23 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 baseline care plan within 48 hours for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care to four of eight residents (Residents #56, #83, #109, and #120) reviewed for baseline care plan. 1. The facility failed to ensure Residents #56 had a baseline care plan after admission to the facility on [DATE]. 2. The facility failed to ensure Residents #83 had a baseline care plan after admission to the facility on [DATE]. 3. The facility failed to ensure Residents #109 had a baseline care plan after admission to the facility on [DATE]. 4. The facility failed to ensure Residents #120 had a baseline care plan after admission to the facility on [DATE]. These failures could place the residents at risk of not receiving necessary care, treatment, and services upon admission that could result in worsening…

    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 · E2026-04-23 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents received adequate supervision to prevent accidents and/or hazards for 3 (Residents #68, #107, and #110) of 8 residents reviewed for supervision and accidents/hazards.1. The facility failed to ensure there were no germicidal wipes on Resident #107's side table on 04/21/2026.2. The facility failed to ensure there were no germicidal wipes on the floor, in front of Resident #110's room on 04/21/2026.3. The facility failed to ensure Resident #68 received adequate supervision allowing Resident #68 to exit the facility without the knowledge of staff on 04/13/2026 for approximately 20 minutes. Resident #68 was located at Walgreens, which is parallel to the facility approximately 528 yards from the facility. These failures could place residents at risk for injuries, decline in health, and having an environment that was free from exposure to toxic chemicals.Record review of Resident #68's face sheet dated 04/13/2026 revealed a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-23 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for five of twenty residents (Residents #63, #71, #79, #102, and #107) and one of four direct care staff (MA K) reviewed for medication storage. 1. The facility failed to ensure that Resident #71 did not have a pain reliever cream inside his room on 04/21/2026. 2. The facility failed to ensure that Resident #102 did not have a tube of zinc oxide and a bottle of multivitamins inside her room on 04/21/2026. 3. The facility failed to ensure that Resident #63 did not have a tube of zinc oxide inside her room on 04/21/2026. 4. The facility failed to ensure that Resident #79 did not have a tube of zinc oxide inside her room on 04/21/2026. 5. The facility failed to ensure that Resident #107 did not have a roll-on pain relief and a tube of zinc oxide…

    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 before2026-04-23 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of twenty residents (Resident #4, #32 and #71) reviewed for infection control. 1. The facility failed to ensure CNA J did not put Resident #4's catheter bag on top of the resident's bed and changed her gloves after touching the catheter bag on 04/22/2026. 2. The facility failed to ensure CNA H performed hand hygiene and changed her gloves during Resident #32's incontinent care on 04/22/2026. 3. The facility failed to ensure CNA G wore a gown when she emptied Resident #71's catheter bag and when she checked if the resident was wet on 04/21/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings included: 1. Record review of Resident #4'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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-23 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during personal care and confidentiality of personal and medical records for one of twenty residents (Resident #4) reviewed for privacy and confidentiality. The facility failed to ensure CNA I and CNA J closed the blinds of Resident #4's window, which was overlooking the parking lot, during incontinent care on 04/22/2026. This failure could place the residents at risk of not having their personal privacy maintained while care was provided, which could result in the residents feeling uncomfortable during care.Findings included: Record review of Resident #4's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with lumbar spina bifida (the spinal cord fails to form during pregnancy) and weakness. Record review of Resident #4's Comprehensive MDS Assessment, dated 03/14/2026, reflected the resident had a severe 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-23 · 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 observations, 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 included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one of twelve residents (Resident #26) reviewed for care plans. The facility failed to ensure that Resident #26 had a care plan for her BiPAP on 04/21/2026.This failure could place the residents at risk of not receiving the necessary care and services.Findings included: Record review of Resident #26's Face Sheet, dated 04/21/2026, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with a solitary pulmonary nodule (a single round spot in the lung). Record review of Resident #26's Comprehensive MDS Assessment, dated 03/31/2026, reflected that the resident was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one of five residents (Resident #4) reviewed for incontinent care. The facility failed to ensure that CNA J did not place Resident #4's catheter on top of the Resident #4's bed rendering the catheter not below the bladder for the duration of incontinent care on 04/22/2026. This failure could place the residents at risk of backflow of urine resulting to urinary tract infection.Findings included: Record review of Resident #4's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with reflux neuropathic bladder (bladder does not function properly due to damaged nerves). Record review of Resident #4's Comprehensive MDS Assessment, dated 03/14/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 05. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-23 · 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 observations, interviews, and record review the facility failed to ensure that residents who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of six residents (Resident #26) reviewed for respiratory care. The facility failed to ensure Resident #26's BiPAP mask was properly stored when not in use on 04/21/2026. This failure could place residents at risk of respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #26's Face Sheet, dated 04/21/2026, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with a solitary pulmonary nodule. Record review of Resident #26's Comprehensive MDS Assessment, dated 03/31/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-23 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of ten residents (Resident #83) reviewed for pharmaceutical services. The facility failed to ensure LVN F did not administer Resident #83's esomeprazole along with the other medications and the resident's formula on 04/22/2026. This failure placed residents at risk of not receiving the full benefit of their medication. Findings included: Record review of Resident #83's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing) and gastro-esophageal reflux (stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #83's Comprehensive MDS Assessment, dated 04/07/2026, reflected 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-13 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that ensured drugs and biologicals were accurately acquired, received, dispensed, and administered) to meet the needs of each resident for one (east side medication room) of two medication rooms reviewed for pharmacy services. The facility failed to ensure expired medication administration supplies were removed from the east side medication room. These failures could place residents at risk for infection and having possible adverse effects. Findings included: In an observation and interview on [DATE] at 9:16 a.m., expired supplies were found stored on shelves in the east side medication room. Expired supplies observed included: two boxes of 100 count syringes with needles expired on [DATE], two boxes of 100 count syringes with needles expired on [DATE], one box of 100 count syringes with needles expired on [DATE], and four boxes of 100 count syringes without needles expired on…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · E2025-02-13 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #29) of 19 residents reviewed for medication errors. The facility failed to ensure Clonazepam (a drug used to control seizures and/or anxiety) was administered to Resident #29 as ordered from 9/10/2024 until 2/12/2025 (155 days). This failure could place residents at risk for not receiving medications as ordered by their physician and not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #29's Annual MDS assessment dated [DATE] revealed Resident #29 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of anxiety disorder and seizure disorder. The MDS also revealed a BIMS score of 13 (it suggested cognition was intact). Record review of Resident #29's care plan revised on 1/24/2025 revealed Resident #29 had a seizure disorder and interventions were to give seizure medications as…

    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 before2025-02-13 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles and secured properly for two (500 hall medication cart and 200 hall medication cart) of four medication carts reviewed for medication labeling and storage. 1. The facility failed to ensure eye drops stored on the 500-hall medication cart were labeled with open dates for two bottles of timolol eye drops, one bottle of dorzolamide eye drops, one bottle of brimonidine eye drops, and one bottle of latanoprost eye drops. 2. The facility failed to ensure medications were secured or attended by authorized staff when the medication cart in hall 200 was left unlocked and unattended in the hallway with a pill in a medicine cup on top of the cart. These failures could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations and of not receiving the intended therapeutic effects of prescribed medicine. Findings included: 1. In an interview and…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's main kitchen reviewed for food safety. 1. The facility failed to ensure food items in the refrigerator and dry storage room were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to discard items stored in refrigerator or dry storage that were not properly labeled or past the 'best buy', discard by or expiration dates. 3. The facility failed to have dietary staff wash hands or change gloves when they touched other surfaces while handling food or upon re-entering the kitchen. 4. The facility failed to have the handwashing sink trash receptacles function properly. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of the Kitchen on 02/11/25 at 10:00 AM revealed the following: -Handwashing sink #1's (next to ice machine) trash receptacle did not function…

    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 · Dcited before2025-02-13 · 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 reviews, the facility failed to establish and maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection for one (Resident #85) of three residents reviewed for infection control. The facility failed to ensure RN D used proper infection control precautions when entering the room of Resident #85 who was on droplet precautions due to testing positive for COVID. This failure could place residents at risk for infections. Findings included: Record review of Resident #85's admission MDS assessment dated [DATE] revealed Resident #85 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of diabetes, morbid obesity, and gangrene (dead tissue caused by bacteria or lack of blood flow). The MDS also revealed a BIMS score of 15 (suggested no cognitive impairment). Record review of Resident #85's care plan with a revision date of 2/04/2025 revealed Resident #85 was on strict contact isolation…

    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 · Ecited before2024-01-11 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's kitchen, reviewed for kitchen sanitation. The facility failed to ensure food in the facility's walk-in refrigerator was covered. The facility failed to ensure the ice machine was clean and sanitized. The facility failed to ensure the tea was covered with a lid. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observation on 01/09/2023 from 9:05 AM to 09:20 AM in the facility's kitchen revealed: 1. Two tea dispensers inside the kitchen with tea were not covered. 2. The ice machine inside the kitchen had a brown residue on the side wall. 3. The walk-in refrigerator had mandarin orange slices in a tray without any coverings. An interview with the Dietary Manager on 01/11/2024 at 12:46 PM, she stated the expectation of the kitchen staff was to make the tea an hour before the meal service and the tea…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-11 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #310, Resident #102, Resident #21, Resident #83, and Resident #68) of eight residents reviewed for infection control. 1. RN C failed to prevent cross contamination of Resident #310's Insulin pen when he placed a soiled glucometer next to the pen and then administered insulin to the resident with the soiled pen. 2. CNA B failed to perform hand hygiene during incontinence care for Resident #102. 3. The facility failed to prevent Resident #21's catheter bag, that was connected to her urostomy (an opening in the belly to redirect urine flow from the urinary system to the outside of the body), from contact with the floor. 4. MA D failed to sanitize the blood pressure cuff between uses on Resident # 83 and 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-11 · 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 ensure residents had the right to reside and receive services with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for two of ten residents (Resident #59 and Resident #77) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #59 and #77's rooms were in a position that was accessible to the residents. This failure could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings include: 1. Record review of Resident #59's face sheet, dated 01/10/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #59 had relevant diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (insufficient…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #102) of two residents reviewed for incontinence care. The facility failed to ensure CNA B provided appropriate perineal care for Resident #102 after an incontinent episode when she failed to wipe from the base of the labia towards and extending over the resident's buttocks. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings include: Record review of Resident #102's 5-day MDS assessment, dated 12/24/23, reflected a [AGE] year-old female with an admission date of 12/21/23. Resident #102 had a BIMs of 11, which indicated she was moderately cognitively impaired. She required extensive assistance of one-to-two-persons with all ADLs and was always incontinent of bowel…

    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 before2024-01-11 · 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 Immediate Supervisor: [NAME] Alfafara Based on observation, interview, and record review, the facility failed to ensure that a resident, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #72) reviewed for respiratory care. The facility failed to ensure Resident #72's nebulizer tubing was changed weekly as scheduled. This failure could place the resident at risk for respiratory infection and not having their respiratory needs met. Findings include: Record review of Resident #72's face sheet, dated 01/10/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #72's relevant diagnoses which included atrial fibrillation (slow heartbeat) and chronic obstructive pulmonary disease (lung disease). Record review of Resident #72's Comprehensive MDS Assessment, dated 10/31/2023, reflected Resident #72's BIMS score…

    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
  • No harm found · C2026-04-23 · 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 the nurse staffing data information was posted daily for 1 of 1 facility reviewed for required postings.The facility failed to post the daily staffing information for 04/20/26.This failure could place residents, family members, and visitors at risk of not having access to information regarding staffing data and facility census.Findings included:During an observation on 04/21/26 at 5:35 AM, revealed a document labeled Daily Staffing Log and dated 04/19/2026 which was posted in a plastic protector on a desk in the entranceway across from the ADMIN's office. The document included the staff titles: Registered Nurse, Licensed Vocational Nurse, Certified Nurse Aide, Certified Med Aide. The document included the number of staff under each title, the number of hours, the total number of hours worked for each staff title type, the total number of hours worked, and the daily census. Record review on 04/21/26 at 11:45 AM, of the facility's nursing staff information reflected the facility failed to complete 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.

    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

No federal fines in the current CMS record.

Part of a chain

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

RatingThis homeChain avg
Overall 4 of 52.9+1.1 vs chain
Health inspection 4 of 53.2+0.8 vs chain
Staffing 3 of 51.6+1.4 vs chain
Quality measures 4 of 53.4+0.6 vs chain
The other 37 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Alpine Skilled Nursing and RehabilitationRuston, LA 1 of 5Bridgeport Medical LodgeBridgeport, TX 1 of 5Camelot Rehabilitation At Magnolia ParkLafayette, LA 1 of 5Colonial Oaks Skilled Nursing and RehabilitationBossier City, LA 1 of 5Hilltop Park Rehabilitation And Care CenterWeatherford, TX 1 of 5Pilgrim Manor Skilled Nursing and RehabilitationBossier City, LA 1 of 5Shreveport Manor Skilled Nursing & RehabilitationShreveport, LA 1 of 5St Joseph Skilled Nursing and RehabilitationMonroe, LA 1 of 5The Bradford Skilled Nursing And RehabilitationShreveport, LA 1 of 5The Guest House Skilled Nursing and RehabilitationShreveport, LA 2 of 5Booker T. Washington Skilled Nursing and RehabilitShreveport, LA 2 of 5Decatur Medical LodgeDecatur, TX 2 of 5Resthaven Living CenterBogalusa, LA 2 of 5Ridgmar Medical LodgeFort Worth, TX 3 of 5Broadmoor Medical LodgeRockwall, TX 3 of 5Camelot Of BroussardBroussard, LA 3 of 5Chateau St. James Rehab And RetirementLutcher, LA 3 of 5Louisiana Extended Care Hospital Of LafayetteLafayette, LA 3 of 5Mabank Nursing CenterMabank, TX 3 of 5Royse City Medical LodgeRoyse City, TX 3 of 5The Homestead of DenisonDenison, TX 3 of 5The Woodlands Healthcare CenterLeesville, LA 3 of 5Timber Springs Rehab and RetirementSpringhill, LA 4 of 5College Park Rehabilitation And Care CenterWeatherford, TX 4 of 5Jo Ellen Smith Convalescent CenterNew Orleans, LA 4 of 5Mansfield Medical LodgeMansfield, TX 4 of 5The Parks at Garland Healthcare and RehabGarland, TX 4 of 5Victoria Gardens Of AllenAllen, TX 4 of 5Victoria Gardens of FriscoFrisco, TX 4 of 5Vista Ridge Nursing & Rehabilitation CenterLewisville, TX 4 of 5Windmill Village Rehabilitation & Care CenterLubbock, TX 5 of 5Camelot BrooksideJennings, LA 5 of 5Chateau D'Ville Rehab and RetirementDonaldsonville, LA 5 of 5Chateau Terrebonne Health Care CenterHouma, LA 5 of 5Grapevine Medical LodgeGrapevine, TX 5 of 5Spring Lake Skilled Nursing And RehabilitationShreveport, LA 5 of 5Springtown Park Rehabilitation And Care CenterSpringtown, TX

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

Who owns this facility

Owner / managerTypeRoleShareSince
FANNIN COUNTY HOSPITAL AUTHORITYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/01/2025
BAUDER FAMILY INVESTMENTS, LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 05/01/2025
BOULWARE ST JAMES LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 03/01/2025
PMG REALCO-MCKINNEY, LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 05/01/2025
BAUDER, KELLYIndividual5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 05/01/2025
BAUDER, MADISONIndividual5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 03/01/2025
BAUDER, PARKERIndividual5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 03/01/2025
BAUDER, WILLIAMIndividual5% OR GREATER MORTGAGE INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
BOULWARE, DOUGLASIndividual5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 05/01/2025
BOULWARE, SANDRAIndividual5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 03/01/2025
BOULWARE, STEVENIndividual5% OR GREATER MORTGAGE INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
BOULWARE, THOMASIndividual5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 05/01/2025
WALKER, KATIEIndividual5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 03/01/2025
SANDERSON, CLARKIndividualCORPORATE DIRECTORsince 05/01/2025
PMG OPCO - MCKINNEY LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/20/2025
BRIDGEPOINTE FINANICAL SERVICES, LLCOrganizationADP OF THE SNFsince 05/01/2025
INNOVATIVE NURSE CONSULTING, LLCOrganizationADP OF THE SNFsince 03/01/2025
PRIORITY MANAGEMENT GROUP, LLCOrganizationADP OF THE SNFsince 03/01/2025
PROGRESSIVE REHAB SOLUTIONS, LLCOrganizationADP OF THE SNFsince 03/01/2025
ALI, MALIKIndividualADP OF THE SNFsince 03/01/2025
ROBINSON, JOHNIndividualADP OF THE SNFsince 03/01/2025

CMS files one row per role, so the 36 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted.

9 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.

$12.3M
Net patient revenuemost recent cost report
+3.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 4%Medicare 21%Other / private 74%

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

$361per resident / day
operating cost
$10,960per month
≈ monthly operating cost
$373per 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 676367. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-23, 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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