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Ashton Medical Lodge

801 South Loop 250 West, Midland, TX 79703 · For profit - Limited Liability company · 144 certified beds · (432) 689-2100 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent May 20251 immediate-jeopardy citation$13,397 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent May 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $13,397 in federal fines (most recent 2023-12-21)
  • its payroll-based staffing rating is low (1/5)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5615 Deauville Blvd · (432) 221-2300 · Call to confirm hours
Pharmacy
5407 ANDREWS HIGHWAY
Grocery
4711 Crockett Ave · (432) 967-9875 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
301 N Loop 250 W · (432) 681-8200

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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 increased11.2%15.8%15.4%better
Long-stay residents who lose too much weight1.8%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.7%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.9%0.8%2.0%typical
Long-stay residents with depressive symptoms22.0%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 injury8.1%3.3%3.3%worse
Long-stay residents whose ability to walk worsened16.1%14.0%16.1%typical
Long-stay residents on antianxiety or hypnotic medication16.5%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers4.8%3.8%4.7%typical
Long-stay residents with worsening bladder/bowel control11.3%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table2.3%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine97.3%88.0%79.4%better
Short-stay residents rehospitalized after admission24.6%25.7%22.6%typical
Short-stay residents with an outpatient ER visit10.4%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days1.642.171.67typical
Long-stay outpatient ER visits per 1,000 resident days2.062.061.80worse

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.

43.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 156 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

43.5%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
89.7%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 89.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 87 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF43.5%CMS range 32.8–50.251.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 7.3–13.610.7%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 discharge89.7%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 discharge87.4%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 discharge83.9%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 identified99.5%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 stay1.6%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 worsened2.1%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 hospitalization11.3%CMS range 8.4–15.87.1%Oct 2023–Sep 2024worse than U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.501.02Oct 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

0.38
RN hours/ resident / day
0.89
LPN hours/ resident / day
2.12
Aide hours/ resident / day
3.39
Total nurse hours/ resident / day
0.35
RN hoursweekends
49.6%
Total nursing turnover
35.7%
RN turnover

How full it usually is: this home is certified for 144 beds and averages 131.9 residents a day — about 92% 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 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 3.00 hrs/resident/day on weekends vs 3.55 on weekdays — 16% thinner on weekends. RN hours go from 0.40 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% 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

5
deficiencies at the latest standard inspection (2026-04-10)
11
at the previous standard inspection (2025-02-06)

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-01-05 · 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 interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent elopements for 1 (Resident #1) of 7 residents reviewed for accidents and supervision. The facility failed to provide adequate supervision to Resident #1. As a result, Resident #1 eloped from the facility at night along a highway and was located approximately 2 hours later in 44° Fahrenheit weather after he had fallen into a wet drainage ditch. Resident #1 was admitted to the hospital with diagnoses including hypothermia. An Immediate Jeopardy was identified on 01/04/24 at 3:02 PM. While the IJ was removed on 01/05/24 at 6:28 PM, the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed all residents that are an elopement risk at risk for serious injury, harm, and/or death. Findings included: Review of Resident #1'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-10 · 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 store all drugs and biologicals in locked compartments for 1 of 4 nurse medication carts reviewed for medication storage and for 2 of 4 nurse medication carts (hall 1 cart and hall 4 cart) observed for medications stored and properly labeled. LVN A failed to ensure her nurse medication cart was secured when it was left unattended on [DATE]. The hall one nurse medication cart had one insulin pen that belonged to Resident #100 that had been opened but not dated when it was placed into use. This these failures could place clients at risk for drug diversion or accidental ingestion and could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: Unlocked and unattended medication cart. Observation and interview on [DATE] at 09:55 AM the nurse medication cart for hall 5 was seen unlocked and unattended for at least 10 minutes. The cart was parked in the hallway and there were no…

    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 · Dcited before2026-04-10 · 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 that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #64) reviewed for transfers. CNA H and CNA I performed an incorrect two-person transfer on Resident #64 on 4/6/26. This failure could place residents who required assistance during transfers at risk of pain and injury. Findings included:Record review of Resident #64's admission Record, dated 4/8/26, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, arthritis, weakness, and abnormalities of gait and mobility. Review of Resident #64's Quarterly MDS Assessment, dated 2/6/26, revealed:She had a BIMS score of 3 of 15 (indicating severe cognitive impairment)She needed substantial assistance with transfers. Review of Resident #64's Care Plan, last updated 4/6/26, revealedFocus: Resident requires assistance with late loss ADL's and use of wheelchair for…

    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 before2026-04-10 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one Resident (Resident #16) of two reviewed for Percutaneous Endoscopic Gastrostomy (PEG-a tube inserted through the abdomen into the stomach for the purpose of administering liquid nutrition and medications) received the appropriate treatment and services to prevent complications and aspiration. LVN E failed to check PEG tube placement by auscultating (Listening with stethoscope) and checking for residual prior to administering Resident #16's medication as ordered by the physician. This failure placed residents who had a PEG tube at risk for complications, aspiration, and pneumonia. Findings include.Record review of Resident #16's admission record dated 04/07/2026 revealed she was admitted to the facility on [DATE] with diagnosis of gastrostomy status (Gastrostomy status indicates that a person has a surgically placed tube providing direct access to the stomach for nutrition, hydration, or medication). She was [AGE] years of age.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-10 · 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 residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 7 residents (Resident #51) reviewed for respiratory care in that: Residents #51's oxygen nasal cannula tube was not bagged when not in use. This failure could place the residents at risk of infection. Findings included: Review of Resident #51's admission record, dated 04/09/2026, indicated she was admitted to the facility on -05/10/2024 with diagnoses of lack of coordination and muscle weakness. She was [AGE] years of age. Review of Resident #51's physician order report dated 04/09/2026 indicated in part: Oxygen - continuously = Oxygen at 2L/PM via nasal cannula continuously. Check every shift. Check O2 sats Q shift and keep O2 at or greater than 92% Record O2 sats every shift. every shift related to heart failure. Review of Resident #51's care plan revised on 04/02/2026 indicated in part: The resident is at…

    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 before2026-04-10 · 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 for 1 (Resident #8) of 1 resident reviewed for expired medications. The hall four nurse medication cart had one insulin pen that belonged to Resident #8 that had expired. This these failures could place clients at risk for drug diversion or accidental ingestion and could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included:Review of Resident #8's admission record dated 04/08/2026 revealed he was admitted to the facility on [DATE] with diagnosis of diabetes type 2. He was [AGE] years of age. Review of the current care plan for Resident #8, last reviewed/revised: 06/12/2025, revealed in part: The resident had diabetes. Humalog KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale subcutaneously before meals for diabetes. Review of Resident #8's physician orders dated 04/08/2026. Humalog KwikPen…

    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 · D2025-05-16 · 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 interview and record review, the facility failed to ensure the right to be free from abuse was provided for 1 (Resident #1) of 15 residents reviewed for abuse, in that: The facility failed to protect Resident #1 from abuse on 4.24.25 when Resident #1 was handled roughly by CNA A. These failures could place residents at risk of abuse, injury, intimidation, fear, agitation, and psychological harm. Findings included: Resident #1 was an [AGE] year-old female admitted to the facility on 1.24.22 with diagnoses of lack of coordination, urinary tract infection, anxiety disorder, and type 2 diabetes mellitus. Resident #1's quarterly BIMS status was completed on 4.9.25 with a score of 5, indicating severe cognitive impairment. Record review of CPS report dated 4.24.25 indicated PRIMARY CONCERNS: Today was 04/24/2025, MF contacted LA. MF stated NR was being aggressive CL. MF took off CLs shirt aggressively and grabbed her by the waste and was placed on the bed making a sound. NR was able to observe the incident…

    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 · D2025-05-16 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's right to be free from misappropriation of resident property for 1 of 16 residents (Resident #3), reviewed for drug diversion. The facility failed to prevent the misappropriation of an unknown number of Resident #3's Lorazepam Oral Concentrate 1MG/0.5ML (Controlled Substance requiring double lock and count every shift) on 08/03/2024 from the medication cart that was never found. This failure could place residents at risk of misappropriation, and could result in increased pain, and poor quality of life. Findings included: Review of Resident #3's face sheet revealed a [AGE] year-old female admitted to the facility on 10.31.23 with the diagnoses of fracture of sacrum, pressure ulcer of sacral region, dementia, and anxiety disorder. Resident #3's quarterly BIMS status was completed on 4.28.25 with a score of 1, indicating severe cognitive impairment. Review of Resident #3's Comprehensive Care Plan last revised 10.20.24,…

    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 · D2025-05-16 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated, for 1 (Resident #4) of 8 residents reviewed for investigating alleged verbal abuse. On Tuesday 4.15.25 Resident #4 reported that she was hit by an employee at night. The Facility did not investigate the allegation of physical abuse. The failure could place residents at risk for abuse. The findings included: Resident #4 was an [AGE] year-old female admitted to the facility on 10.30.20 with diagnoses of Parkinson's disease, hypertension, dementia, and chronic pain. Resident #4's quarterly BIMS status was completed on 4.28.25 with a score of 7, indicating moderate cognitive impairment. Record review of facilities incident report dated 4.15.25 at 9:00 pm indicated: Resident states that she was hit by an employee last night. She was unable to give a name or description of an alleged perpetrator. During an interview of Resident #4 on 5.15.25 at…

    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 · Ecited before2025-02-06 · 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 observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. -The facility failed to keep a plastic bottle of barbeque sauce free of dried drippings around sides of the bottle. -The facility failed to keep spice bottles completely sealed. These failures could place residents at risk of food borne illnesses. Findings included: Observation on 02/04/2025 at 09:05, with the Dietary Manager during the initial tour in the kitchen, revealed the following:, The food preparation area by the food warmer revealed: -16 plastic bottles of spices stored on metal shelves directly above the food preparation area of which 5 spice bottles had opened tops. The refrigerator revealed the following: -A plastic bottle of barbecue sauce had dry dripping running down the side of the neck of the bottle. Interview with the Dietary Director on 02/06/25 at 12:56 PM revealed that staff were trained to close all containers…

    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 before2025-02-06 · 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

    Based on observations, interviews and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for the residents during lunch service observation. -The Director of Rehabilitation did not don gloves or properly disinfect resident's bodily fluids observed on the floor of the main dining room. This failure could place the residents at risk for communicable diseases or viruses. The findings included: In an observation on 02/04/25 at 12:28 PM, a resident was observed spitting on the floor and the facility's Director of Rehabilitation moved the resident to another table. He was then observed using a paper towel without gloves to wipe a resident's spit on the floor next to the dining room table with other residents present and eating their lunch. The Director of Rehab was observed cleaning the area with new paper towels and without gloves. He was observed using the same paper towel to…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · Dcited before2025-02-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to ensure that the resident has a right to a dignified existence and treat each resident with respect and dignity for 1 (Resident #45) of 8 residents reviewed. Resident #45's nephrostomy bag (a sterile disposable bag used to collect urine that is drained from the kidney through a tube) was not placed in a privacy bag. This failure could place residents at risk of diminished quality of life and compromise residents' dignity. Findings include: Record review of Residents # 45's face sheet dated 02/05/2025 revealed she was admitted on [DATE] and readmitted on [DATE]. Record review of Residents # 45's history and physical dated 07/24/2024 revealed a 75-years-old-female diagnosed with other mechanical complication of other urinary devices and implants, pain due to genitourinary prosthetic devices (medical implants designed to restore or improve the function of the urinary system), hydronephrosis (a condition that occurs when urine backs up into…

    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 · D2025-02-06 · 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 were provided services with reasonable accommodation of needs and preferences for 2 (Resident #20, Resident #38) of 8 residents. Resident call lights were not kept within reach for Resident #20 and Resident #38 This failure places residents at risk of having needs unmet when they are unable to contact staff. Findings included: Resident #20 Record review of Resident #20's face sheet dated 02/04/25 revealed he was admitted on [DATE]. Record review of Resident #20's history and physical dated 01/26/24 revealed he was an [AGE] year-old male diagnosed with generalized muscle weakness, difficulty in walking, abnormalities with mobility and lack of coordination. Record review of Resident #20's MDS revealed he had a BIMS score of 3 indicating severe cognitive impairment. Review of Resident #20's Functional Abilities revealed he required moderate assistance with oral hygiene and upper body dressing as well as maximal assistance with…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 1 of 6 residents (Resident #18) reviewed for ADL s. The facility failure to provide nail trimming for Resident #18. This failure placed the resident at risk for injury, infection and decreased quality of life. Findings include: Record review of the Face Sheet for Resident #18 revealed she was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the following diagnoses: Muscular dystrophy (a group of genetic diseases that cause progressive weakness and loss of muscle mass), Type 2 Diabetes Mellitus. Record review of Resident #18's history and physical dated 12/03/24 revealed she is an [AGE] year-old female diagnosed with Muscular Dystrophy with progressive weakness, and Diabetes Mellitus type 2. Record review of Resident #18's care plan dated 02/06/25 revealed 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 · D2025-02-06 · 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 observations, interview, and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #45) of 8 residents reviewed. Resident #45's urinary catheter nephrostomy bag bag was not placed below the bladder. This deficient practice could place the residents at risk of urinary tract infections. Findings include: Record review of Residents # 45's face sheet dated 02/05/2025 revealed she was admitted on [DATE] and readmitted on [DATE]. Record review of Resident # 45's history and physical dated 07/24/2024 revealed a 75-years-old-female diagnosed with other mechanical complication of other urinary devices and implants, pain due to genitourinary prosthetic devices (medical implants designed to restore or improve the function of the urinary system), hydronephrosis (a condition that occurs when urine backs up into the kidney), acute kidney failure with tubular necrosis (a type of kidney…

    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 before2025-02-06 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment to prevent complications for 1 of 1 residents (Resident #83) reviewed who received their feeding through a percutaneous endoscopic gastrostomy (PEG) feeding tube. The facility failed to ensure CNA C and CNA E did not lower the head of the bed flat while the PEG (A PEG tube is a thin, flexible tube inserted through the abdominal wall and into the stomach. It is used to provide nutrition and medications to patients who cannot eat or drink normally) pump was still infusing the formula, during personal care performed for Resident #83. This failure could affect residents with PEG tubes and could result in unwanted outcomes such as aspiration pneumonia. The findings: Record review of Resident #83's admission record dated 02/06/25 indicated she was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing) and dementia. She was [AGE] years…

    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 before2025-02-06 · 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 reviews the facility failed to ensure that a resident who neededs respiratory care was provided such care, consistent with professional standards of practice for 1 (Resident #29) of 17 residents observed for oxygen management. - The facility failed to ensure Resident #29's oxygen tank was not empty behind her wheelchair while she was in the dining area. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings included: Resident 29 Record review of Resident #29's face sheet dated 02/06/25, revealed an, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #29's medical diagnoses dated 02/06/25, revealed, an [AGE] year-old female diagnosed with history of pneumonia unspecified organism and , chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs). Record review of Resident #29's MDS dated [DATE], revealed…

    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 before2025-02-06 · 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

    Based on observations, interviews, and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 (Hall 5 nurse cart) of 4 medication carts inspected for medication reconciliation. RN A did not document the administration of a controlled medication (Tramadol) on the individual controlled medication records after she had administered the medication on 02/04/2025. This failure could place residents at risk of under dose, overdose, and drug diversion. The findings were: During an observation on 02/04/25 at 10:46 AM the medication cart for hall 500 was inspected with RN A present. The controlled medication drawer was checked, and the medications were compared with their corresponding medication sheet. Two of the medication packets were found to be off by 1 number. The medication was Tramadol 50mg, the medication packet contained 20 pills, and the corresponding count sheet indicated 21 pills left in the packet. The second medication was Tramadol 50mg, and the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-06 · tag F0761 — failed to label and store drugs safely — isolated
    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 observations, interviews, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Hall 500 Nurse Med Cart) reviewed for medication storage. The facility failed to ensure the Hall 500 Nurse Medication Cart contained an insulin pen with an open date. This failure could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings included: During an observation on 02/04/25 at 10:46 AM the medication cart for hall 500 was inspected with RN A present. On the top drawer were several insulin pens. One of the insulin pens had been opened but there was no open date observed on the pen. During an interview on 02/04/25 at 10:55 AM RN A said that she was not sure why the insulin pen did not have an open date on it. The RN said she usually dated it when she opened it, the RN disposed…

    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 · D2025-02-06 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 3 diet test trays reviewed for food temperatures. -The facility failed to maintain hot food on the served test trays. -This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: Interviews with residents during initial rounds on 02/04/25 revealed 6 out of 20 residents complained of food being cold when served in their rooms. An observation on 02/05/25 at 5:45 PM revealed sample trays transported in open rolling cart because they did not fit in the insulated cart. One tray for a resident was observed to be placed on top of the insulated cart, due to it not fitting in the cart. Trays for the hall and sample trays all exited the kitchen at 5:53 PM and were taken to hall 500, all trays served to residents. Sample trays then transported to the conference room. Sampling of the test trays on 02/05/25 at 6:05 PM in 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-30 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 3 of 6 residents (Residents #1, #2, and #3) observed for resident rights. The facility failed to ensure staff assisting Residents #1, #2, and #3 did not stand while feeding them. This failure could place residents at risk for decreased meal satisfaction. The findings included: Review of Resident #1's admission Record dated 5/30/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including strokes, paralysis on one side, and brain cancer. Review of Resident #1's quarterly MDS assessment, dated 5/1/24, revealedshe scored a 0 of 15 on her mental status exam (indicating severe cognitive impairment). She needed substantial to maximum assistance for eating. Review of Resident #1's care plan, last revised on 1/12/24 revealed Focus: Resident required extensive…

    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 · Fcited before2023-12-21 · 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 for food service safety for 1 of 1 kitchen: The facility failed to label and date food items. The facility failed to maintain cleanliness in the kitchen. The kitchen staff did not practice proper hand hygiene. These failures could place residents who received meals prepared in the kitchen at risk for ingesting food borne pathogens resulting in gastrointestinal discomfort or illness and cross-contamination. Findings include: During an observation on 12/19/23 at 8:10 am during a walk-through inspection of the kitchen accompanied by the Dietary Director revealed the following: There was a large plastic bin with yellow particles in the dry storage room that did not have a label or date, and the cover was open and exposed to air. There were crumbs and other food particles on the shelf above the food preparation table. In an interview on 12/19/23 at 8:48 am with the Dietary Director, the Dietary Director was asked about the open 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-21 · 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 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 biological, to meet the needs of 1 of 10 residents (Resident #271), 3 of 8 Medication Carts (400 Hall Nurse Medication Cart, 500 Hall Nurse Medication Cart, and 500 Hall Medication Aide Cart) reviewed for pharmacy services. - The facility failed to ensure the 400 Hall Nurse Medication Cart did not include two loose pills. - The facility failed to ensure the 500 Hall Nurse Medication Cart did not contain expired Tramadol medication. - The facility failed to ensure the 500 Hall Medication Aide Cart did not include three loose pills and an expired ophthalmic solution. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and worsening of symptoms of diseases. Findings included: In an observation on 12/21/23 at…

    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 · Dcited before2023-12-21 · tag F0761 — failed to label and store drugs safely — isolated
    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 store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to medications in medication cart 1 of 8 reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication cart #1 was locked when unattended on [DATE]. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: During an observation and interview on [DATE] at 9:30AM revealed Medication cart #1 was left unattended and unlocked by LVN B. The Surveyor was observing medication administration with LVN B. LVN B walked away from her medication cart to central supply, leaving her medication cart unlocked and unattended for 7 minutes. LVN B stated that she was not accustomed to passing medications for the entire hall and that she could not be perfect. LVN B stated she was aware that…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-21 · 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #72) of 4 residents reviewed for infection control. The facility failed to ensure RN A washed or sanitized her hands prior to putting gloves on and administering medication to Resident #72. This failure could place resident's risk for cross contamination and the spread of infection. Finding include: Record review of Resident #72's admission record dated 12/21/23 indicated she was admitted to the facility on [DATE] with diagnosis of osteomyelitis (inflammation or swelling that occurs in the bone). She was [AGE] years of age. Record review of Resident #72's order summary report dated 12/21/2023 indicated in part: (Piperacillin Sodium-Tazobactam Sodium in Dextrose) Use 1 dose intravenously four times a day for…

    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

“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

$13,397 in federal fines across 1 penalty.

  • $13,397 — penalty dated 2023-12-21

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
BOWERMAN, STEPHENIndividualCORPORATE OFFICERsince 03/01/2023
DAVID W MILLER GS TRUSTOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2023
FOURSQUARE TEXAS 16 LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2023
JEC GS TRUSTOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2023
JOHN E MILLER GS TRUSTOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2023
KINGSBURY CAPITAL LLC SERIES FOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2023
KJC GS TRUSTOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2023
LION PLAZA LPOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2023
MNH-INV SERIES LLC SERIES DOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2023
RICHARD M MILLER GS TRUSTOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2023
HAMPTON, BRODERICKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2023
LEWIS, SHANEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2023
CAMPBELL, JOHNIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 05/06/2026
CAMPBELL, KENNETHIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 05/06/2026
MILLER, DAVIDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 05/06/2026
MILLER, JOHNIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 05/06/2026
MILLER, RICHARDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 05/06/2026
DWM 5X5 TRUSTOrganizationADP OF THE SNFsince 03/01/2023
FAIRBROOK PARTNERS, LPOrganizationADP OF THE SNFsince 03/01/2023
JEM 5X5 TRUSTOrganizationADP OF THE SNFsince 03/01/2023
MIDLAND NH REALTY LTDOrganizationADP OF THE SNFsince 03/01/2023
MONTAGUE NH, LPOrganizationADP OF THE SNFsince 03/01/2023
RMM 5X5 TRUSTOrganizationADP OF THE SNFsince 03/01/2023
ROCKETT, LPOrganizationADP OF THE SNFsince 03/01/2023
SDL GS 5X5 TRUSTOrganizationADP OF THE SNFsince 03/01/2023
ATKINS, JEFFREYIndividualADP OF THE SNFsince 03/01/2023

CMS files one row per role, so the 28 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

17 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.

$8.6M
Net patient revenuemost recent cost report
+6.5%
Operating marginrevenue minus expenses
$543K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 63%Medicare 19%Other / private 18%

This home reported $543K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$290per resident / day
operating cost
$8,802per month
≈ monthly operating cost
$310per 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 676430. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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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