No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Park View Nursing Care Center

1100 W Ave J, Muleshoe, TX 79347 · Government - Hospital district · 74 certified beds · (806) 272-7578 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609, F0610) — most recent Apr 2026Resident-funds citations (F0568, F0569)2 immediate-jeopardy citations$14,069 in federal fines1 Medicare payment denial
Insights

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

Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has citations for mishandling residents’ money or property (F0568, F0569)
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,069 in federal fines (most recent 2026-01-15)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (67%) runs well above the national median (45%)

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.

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

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
208 W 2nd St · (806) 272-5538 · Call to confirm hours
Pharmacy
1411 W American Blvd · (806) 272-7511 · Call to confirm hours
Grocery
104 W 9th St · (806) 600-1241 · Call to confirm hours
Park
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 1 of 5
Long-stay residentspeople who live here 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 1 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 rating1★
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 increased36.7%15.8%15.4%worse
Long-stay residents who lose too much weight3.3%3.0%5.4%better
Long-stay residents with a catheter left in their bladder1.7%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection5.3%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%2.4%6.5%check this — see note marked star 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 injury0.9%3.3%3.3%better
Long-stay residents whose ability to walk worsened27.1%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication9.6%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers7.4%3.8%4.7%worse
Long-stay residents with worsening bladder/bowel control17.6%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.7%9.6%17.1%better
Long-stay hospitalizations per 1,000 resident days2.232.171.67worse
Long-stay outpatient ER visits per 1,000 resident days2.662.061.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

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

0.22U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 28% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 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

0.62
RN hours/ resident / day
0.96
LPN hours/ resident / day
1.91
Aide hours/ resident / day
3.49
Total nurse hours/ resident / day
0.54
RN hoursweekends
66.7%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 74 beds and averages 33.9 residents a day — about 46% occupied, or roughly 40 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.95 hrs/resident/day on weekends vs 3.70 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.65 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 67% is well above the national median of 45%. 1 administrator has left in the past year.

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

8
deficiencies at the latest standard inspection (2026-01-15)
6
at the previous standard inspection (2024-10-24)

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.

26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · J2026-02-06 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to consult with the resident's physician when there is a significant change in the resident's physical, mental, or psychosocial status: that is, a deterioration in mental health, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 residents (Resident #2) for a change of condition. The DON failed to immediately consult with Resident #2's physician when she was found in her bed unresponsive but was still breathing on 1/22/26 at approximately 4:30 a.m. At approximately 11:10 a.m., Resident #2 had seizure like activity and was sent to the hospital. Resident #2 was diagnosed with a non-traumatic brain hemorrhage and subsequently died. An IJ was identified on 2/5/26. The IJ template was provided to the facility on 2/5/26 at 4:00 p.m. While the IJ was removed on 2/6/26 at 1:57 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than…

    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
  • Immediate jeopardy · J2026-02-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for 1 of 5 residents (Resident #2) who were reviewed for quality of care. The facility failed to provide the care and services to Resident #2 when her physician was not contacted on 1/22/26 at approximately 4:30 a.m. when she was found in her bed unresponsive but still breathing. Because the physician was not contacted or included in Resident #2's change of condition, she did not receive the best care available. An IJ was identified on 2/5/26 at 4:00 p.m. While the IJ was removed on 2/6/26 at 1:57 p.m., the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, 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 · D2026-04-01 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 (Resident #1 and Resident #2) of 5 residents reviewed for abuse/neglect policy implementation.The facility failed to implement their abuse policy and report to state within 2 hours when Resident #2's family member alleged to RN F that Resident #1 entered Resident #2's room and hit her in the face on the evening of 03/19/26.This failure could place residents at risk of abuse and neglect occurring and/or continuing.Findings Included:Record review of Resident #1's admission record dated 04/01/26 revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) and pseudobulbar affect (inappropriate…

    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 · Dcited before2026-04-01 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #1 and Resident #2) of 5 residents reviewed for reporting of abuse/neglect allegations.The facility failed to report 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-01 · 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 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 1 (Resident #3) of 5 residents reviewed for medication administration.The facility failed to ensure LVN B administered Resident #3's morning medications within an hour of the ordered time on 03/29/26.This failure could place residents at risk of increased disease symptoms and/or diminished quality of life.Findings Included:Record review of Resident #3's admission record dated 04/01/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified focal traumatic brain injury with loss of consciousness of unspecified duration sequela (condition resulting from a head injury that leads to specific focal brain damage with long-term effects/complications), post traumatic seizures (seizures 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 · D2026-02-26 · tag F0568 — isolated
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to establish and maintain an effective system of accounting and record keeping according to generally accepted accounting systems, for 2 of 5 residents (Resident #1, 2) reviewed for trust fund accounting. The facility failed to: Ensure residents with a trust fund were given a full and complete recording of their trust fund transactions when requested (Resident #1)Maintain an accurate running ledger for each resident (Resident #1 and #2)Ensure residents were provided with a financial record of purchases and a quarterly statement at least quarterly or upon request.(Resident #1) These failures could place all residents who had a facility trust fund account at risk of financial misappropriation. Findings included: Findings included:Resident #1 was a 65-y o male admitted to the facility on [DATE] with diagnoses of dementia, Bell's Palsy, depressive disorders and Parkinson's disease. A Care Plan dated 12/23/25 documents resident had tremors, dental issues 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-26 · tag F0569 — isolated
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    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 conveyance of resident funds within 30 days of discharge for 1 of 1 resident (Resident #3) reviewed. The facility failed to ensure Resident #3's funds were conveyed after death within 30 days. This failure could affect residents by not giving them access to funds in a timely manner. Findings included: Resident #3 was an 87-y o female admitted to the facility on [DATE] with diagnoses of unspecified dementia, chronic kidney disease, convulsions, depression, atrial fibrillation and anemia. A Care Plan dated [DATE] documented resident was incontinent, at risk for falls, and had complaints of pain. A Quarterly MDS dated [DATE] documents a BIMS score of 8 out of 15 which indicates cognition was moderately impaired. Review of Resident #3's admission packet did not reveal any family members listed or a power of attorney. Nurse's notes dated [DATE] revealed Resident#3 had a seizure during peri care and was sent to the hospital. Hospital records reviewed…

    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 before2026-01-15 · 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, and serve food under sanitary conditions in 1of 1 kitchen when they failed to: A. Ensure facility staff wore hair restraints and beard guards while in the kitchen.B. Ensure stored and cooked food was properly labeled, dated and covered.C. Ensure hand hygiene and use of proper serving utensils was maintained during serving a mealD. Ensure menu substitutions were documented. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: In an observation of the walk-in freezer on 1/13/26 at 10:40 am revealed the following:opened box of biscuits, open to air and unsecured.15 bags of waffles, not in original box, no label or date3 bags of hamburger patties, not in original box, no label or date6 bags of pancakes, not in original box, no label or date3 bags of chicken strips, not in original box, no label or date In an observation and interview on 1/13/26 at 11:20 am revealed [NAME] C had touched various kitchen…

    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 · E2026-01-15 · 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 the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles to include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 (Hall 100 and Hall 200) of 2 medication carts. -1 bottle of Probiotic had an expiration date of 11/2025.-1 bottle of Tylenol had an expiration date of 10/2019.-Resident #1's Novolog did not have an open date on the medication.-Resident #36's Novolog and Lantus did not have open dates on the medications.-Resident #37 had 2 Wexela inhalers that did not have open dates written on the medications-Resident #37's 2-Wexela inhalers had expiration dates of 07/2023 and 10/2023.-2 loose pills were in the bottom of Medication cart for Hall 200. -Half of a loose pill was in the bottom of the narcotic drawer of Medication cart for Hall 100.The facility's failure could place residents at risk for not receiving the intended therapeutic action of the medication.Findings included:During an observation on 01/13/2026 at 10:19 AM of 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 · D2026-01-15 · 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 observation, interview, and record review; it was determined the facility failed to ensure each resident was provided with the right to have personal privacy during medical treatments, for 1 (Resident #8) of 13 residents reviewed for privacy. -RN G and CNA I did not close the window blinds to provide privacy for Resident #8 during wound care. This failure could place residents at risk of feeling shame or embarrassment, lowered self-esteem, and a lack of a dignified existence.Findings Included:Resident #8Record review of Resident #8's clinical record revealed a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses of myelodysplastic syndrome (the bone marrow produces faulty, immature blood cells that don't mature properly, leading to too few healthy red cells (anemia), white cells (infections), and platelets (bleeding)), schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia (psychosis like hallucinations/delusions) with a mood disorder (major…

    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 · D2026-01-15 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #2) of 13 residents reviewed for accuracy of assessment.The facility coded Resident #2 as receiving insulin when she did not receive insulin.This failure could place residents at risk of receiving unnecessary care/medication.Findings Included:Record review of Resident #2's admission record dated 01/13/26 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and unspecified atrial fibrillation (irregular heart rhythm).Record review of Resident #2's annual MDS with ARD of 10/14/25 revealed a BIMS score of 12 which indicated moderately impaired cognition. Section N Medications revealed the following: .…

    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 · D2026-01-15 · tag F0655 — isolated
    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 interviews and record reviews the facility failed to develop and implement a baseline care plan 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 within 48 hours of a resident's admission for 1 (Resident #28) of 13 residents reviewed for care planning.The facility failed to develop a baseline care plan for Resident #28 within 48 hours of his admission on [DATE].This failure could place newly admitted residents at risk of not receiving effective, person-centered care.Findings Included:Record review of Resident #28's admission record dated 01/14/26 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement), type 2 diabetes mellitus (insufficient production of insulin, causing high blood…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · Dcited before2026-01-15 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #2 and Resident #28) of 13 residents reviewed for comprehensive care plans.1. The facility failed to include Resident #2's antidepressant medication in her care plan.2. The facility failed to include Resident #28's rash in his care plan.These failures could lead to residents not receiving needed care and or symptom monitoring.Findings Included:1. Record review of Resident #2's admission record dated 01/13/26 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-15 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the meals served reflected the nutritional needs of residents in accordance with established national guidelines for all residents when the facility failed to ensure menus were followed by 6 of 6 residents who received pureed meals. A. The facility did not serve onions and peppers to residents with a pureed meal for the lunch meal on 1/13/26 as directed by the menu. These failures could place all residents who received food from the kitchen at risk of decreased meal satisfaction, potential weight loss due to poor meal intake, not having their nutritional needs met, and a decline in health status. Findings included: In an observation and interview on 1/13/26, at 12:40 pm, 6 residents on a pureed diet did not receive onions and peppers on their meal tray. The residents were given carrots instead. In an interview the DM stated the residents with pureed meals had not received onions and peppers from the posted menu because you could…

    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 · D2026-01-15 · 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

    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 communication diseases and infections for 2 (Resident #1 and Resident #37) of 13 residents reviewed for infection control. -LVN F failed to use proper hand hygiene techniques when preparing and administering medications to Resident #1.-LVN F failed to clean glucometer before and after performing glucose check for Resident #1.-Facility failed to have proper EBP signage on Resident #37 who had a foley catheter. These failures had the potential to affect residents by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases.Findings Included: During an observation on 01/13/2026 at 11:19 AM revealed no signage for enhanced barrier precautions on Resident #37's door. During an interview on 01/13/2026 at 11:19 AM a family member of Resident #37…

    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 · F2025-12-16 · tag F0837 — widespread
    Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the governing body of the facility appointed an administrator, who was licensed by the state, to be responsible for the management of the facility and reported to the governing body for 1 of 1 facility reviewed for governing body.The facility had not had an administrator since 09/02/2025.This could place residents at risk of decreased quality of life and quality of care due to lack of staff oversight and monitoring of care. The findings included: Record review on 12/16/25, of the former Administrator's undated Disciplinary Action Form revealed that the ADM was terminated on 09/02/25 due to violation of personnel policies. During an interview on 12/16/25 at 9:49 a.m., an entrance conference was conducted with the Corporate RN who stated there was not a full time ADM for the facility at this time. She stated she fired the full-time ADM on 09/02/25 for not having a current license and was currently acting on behalf of the facility to hire a new ADM. The Corporate RN stated there was an interim ADM in October 2025, who…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-15 · 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 that assure the accurate dispensing and administering of all drugs for two (Resident #1, #2) of five residents reviewed for pharmacy services. Resident #1 who was nonverbal and bedridden and dependent on staff for all care needs, tested positive for barbiturates on 11/14/2025. The medical record did not contain documentation of a current barbiturate prescription. Resident #2's was prescribed Primidone 50mg, a medication that metabolizes in the body as a barbiturate was missed per the MAR on 11/08/2025 and 11/09/2025. These failures could place residents in the facility at risk of adverse drug reactions, untreated or uncontrolled medical conditions and a decline in health status.Record review of Resident #1's face sheet dated 11/15/2025 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's disease (a progressive disease 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 · Fcited before2024-10-24 · 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 safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure all food in the dry pantry and cold storage were properly sealed, labeled and dated. The facility failed to ensure all foods in the dry pantry were at least 18 inches off the floor as required by facility policy for dry pantry storage. These failures could place residents at risk of residents at risk of food-borne illness and a diminished quality of life. Findings included: On 10/22/2024 at 10:04AM an initial observation of the kitchen was conducted, and the following was noted: Dry Pantry: (3) partial 5lb. bags corn tortillas with no received date and one bag open to air. (1) partial 10lb. bag elbow macaroni with no received date and open to air. (1) partial 50lb. bag white rice with no received date and open to air. (2) 3oz. boxes dry raspberry gelatin with no received date. (1) partial 2lb. 3oz. bag frosted flake cereal with 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-24 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 16 residents (Residents #5 and #27) reviewed for abuse and neglect. The facility failed to report to the Administrator and State Survey Agency an allegation of abuse involving Residents #5 and #27 within 2 hours of the allegation. This failure could place residents at risk of not having incidents of abuse, neglect, exploitation, and misappropriation…

    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 · E2024-10-24 · tag F0610 — failed to investigate and act on abuse reports — pattern
    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 observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 2 of 16 (Residents #5 & #27) residents reviewed for abuse and neglect. The facility failed to conduct a thorough investigation when Resident #5 fell from his wheelchair unobserved and obtained a skin tear to the bridge of nose and abrasion to left side of forehead. The facility failed to conduct a thorough investigation when Resident #27 fall leading to a head wound on her left side. This failure could place residents at risk of abuse and neglect. Findings included: Record review of Resident # 5's face sheet dated 10/23/2024, revealed that the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses, included but not limited to, Neurocognitive Disorder with Lewy Bodies (cognitive decline in thinking abilities, visual perception, and visual hallucinations), Dementia (cognitive loss) with anxiety and agitation, Parkinsonism (slowness of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-24 · tag F0940 — failed to train staff — pattern
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff and individuals providing services under a contractual agreement, consistent with their expected roles for 4 of 11 (interim DON, LVN B, CNA C and CNA D) staff reviewed for nursing home training. The facility failed to ensure Interim DON, LVN B, CNA C and CNA D were trained in the prevention of Resident Abuse, Neglect and Exploitation, HIV Policy and Procedures, Fall Prevention, Use of Restraints, Emergency Procedures and Dementia. This failure could place residents at risk for a diminished quality of life and diminished psychosocial well-being, due to lack of training in essential resident care and facility practice. Findings included: Record review of employee files revealed the following staff did not have training in the prevention of Resident Abuse, Neglect and Exploitation, HIV Policy and Procedures, Fall Prevention, Use of Restraints, Emergency Procedures and Dementia prior to interacting with and caring for residents 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment for 1 of 16 (Resident #5) reviewed for care plans. This facility failed to implement the comprehensive care plan for Resident #5, resulting in a fall with injury. This failure could place residents at risk of not receiving the care needed to live at their highest practicable level of health and mental well-being. Findings included: A review of Resident #5's clinical face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a BIMS of 02 indicating severe cognitive impairment with a diagnosis of, but not limited to, Neurocognitive Disorder with Lewy Bodies (clumps of abnormal protein that, for reasons unknown, accumulate in the brain), Dementia in Other Diseases Classified…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-24 · tag F0727 — failed to provide required RN coverage — isolated
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 (10/12/2024) of the 90 days reviewed. The facility did not have an RN working in the facility on 10/12/2024. This failure has the potential to affect the residents in the facility and place them at risk of not having staff with advance care skills available to assist in their care needs. Findings included: Record review of the facility's last 90 days (07/22/2024-10/22/2024) of RN coverage provided by the BOM revealed the facility had no RN working in the facility for the following date: 10/12/2024. During an interview on 10/22/24 at 12:20 PM, the BOM verified that the facility did not have an RN working in the facility on 10/12/24. During an interview on 10/24/24 at 9:15 AM, the ADON stated that a possible negative outcome for not having an RN working for 8 hours/day would be that if something bad happened, the staff would not know what to do and would not have anyone to go to. During an interview on 10/24/24 at 10:20 AM,…

    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
  • Potential for harm · Fcited before2023-10-18 · 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, and serve food under sanitary conditions in 1of 1 kitchen observed for kitchen sanitation. The facility failed to: A. Ensure general cleanliness was maintained. B. Ensure food items were properly stored. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings include: Observations on 10/16/23 at 10:15 am of the pantry revealed: 1. An opened jar of jelly with a label that stated refrigerate after opening. Observations on 10/16/23 at 10:20 am of the walk-in cooler revealed: 1. A package of shredded cheese, open to air. 2. A package of sliced cheese, open to air. 3. A large bottle of Coffee Mate liquid creamer on the shelf. Label stated do not refrigerate or freeze. Observations on 10/16/23 at 10:20 am of the walk-in freezer revealed: 1. A box of frozen burritos, open to air. Observation of the lunch meal service on 10/16/23 at 12:05 pm revealed the following: The DM was observed with gloved hands touching various…

    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 · D2023-10-18 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 and the facility promoted and facilitated resident self-determination through support of resident choice, which included but not limited to the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 16 residents (Resident #3) reviewed for self-determination. The facility failed to ensure Resident #3 was allowed to choose the type of foods he preferred when he expressed he would like all the foods the other residents were served. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that were important in their life and a decrease in their quality of life. Findings include: Record review of Resident # 3's face sheet revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include vascular dementia (defective memory), dysphagia (difficulty…

    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 before2023-10-18 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the menu was followed, for 2 out of 3 residents that received pureed food (Resident #3 & Resident # 29), in that: 1. The facility failed to ensure Resident # 3 received pureed bread on 10/16/23. 2. The facility failed to ensure Resident # 29 received pureed bread on 10/16/23. These failures could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances. The findings include: Resident # 3 Record review of Resident # 3's face sheet revealed a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses to include vascular dementia (defective memory), dysphagia (difficulty swallowing), and anxiety. Record review of comprehensive MDS assessment dated [DATE] revealed Resident # 3 was usually understood. The MDS revealed Resident # 3 had a BIMS of 10 which indicated the resident's cognition was moderately impaired. Section K indicated Mechanically altered diet: Require change…

    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

“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

$14,069 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $14,069 — penalty dated 2026-01-15
  • Medicare payment denial — starting 2026-03-10 for 17 days

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 / managerTypeRoleShareSince
MULESHOE AREA HOSPITAL DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2006
DEWBERRY, TOMMIEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; ADP OF THE SNFsince 03/01/2024
FLEENOR, DENNISIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; ADP OF THE SNFsince 03/03/2016
MILLER, SCOTTIndividualCORPORATE DIRECTORsince 05/26/2022
SHIPMAN, TODDIndividualCORPORATE DIRECTORsince 05/23/2024
NICHOLS, LANDONIndividualCORPORATE OFFICERsince 01/01/2018
RICHERSON, GAYLEIndividualCORPORATE OFFICERsince 08/01/2018
SMYER, ALLENIndividualCORPORATE OFFICERsince 01/01/2018
WOODWARD, TRACEYIndividualCORPORATE OFFICER; ADP OF THE SNFsince 03/01/2024
RENDON, ROSIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/05/2024
RODRIGUEZ, ROLANDOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2024

CMS files one row per role, so the 18 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$2.5M
Net patient revenuemost recent cost report
-3.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 4%Medicare 11%Other / private 85%

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
$8,806per month
≈ monthly operating cost
$281per 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 676079. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, 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.

What to do next