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

Eden Home

631 Lakeview Blvd, New Braunfels, TX 78130 · For profit - Individual · 122 certified beds · (830) 625-6291 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Dec 20241 immediate-jeopardy citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$45,130 in federal fines1 Medicare payment denial
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)
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $45,130 in federal fines (most recent 2025-05-22)

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.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
652 N Houston Ave · (830) 625-0009 · Call to confirm hours
Pharmacy
386 Landa St · (830) 608-9799 · Call to confirm hours
Grocery
161 S Seguin Ave · (830) 312-5588 · 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 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 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 rating3★
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 increased27.2%15.8%15.4%worse
Long-stay residents who lose too much weight0.0%3.0%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.3%0.3%0.9%typical for the state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.8%0.8%2.0%typical for the state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.6%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.0%3.3%3.3%worse
Long-stay residents whose ability to walk worsened25.8%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication19.3%18.0%18.9%typical
Long-stay residents given the seasonal flu vaccine98.7%98.0%95.3%typical
Long-stay residents with pressure ulcers0.7%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control24.9%13.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table14.0%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine95.1%88.0%79.4%better
Short-stay residents rehospitalized after admission23.3%25.7%22.6%typical
Short-stay residents with an outpatient ER visit13.8%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.802.171.67typical
Long-stay outpatient ER visits per 1,000 resident days0.892.061.80better

* 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.

41.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 167 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.7%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
85.1%U.S. median 56.6%
Met the expected recovery
0.44U.S. median 0.31
Therapy hours / resident / day
0.25hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 85.1% 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 0.44 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF41.7%CMS range 34.5–51.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.2–14.310.7%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 discharge85.1%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 discharge86.2%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 discharge69.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.4%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 stay0.8%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 worsened0.8%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 hospitalization10.2%CMS range 6.2–14.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.241.02Oct 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

0.56
RN hours/ resident / day
0.99
LPN hours/ resident / day
2.43
Aide hours/ resident / day
3.98
Total nurse hours/ resident / day
0.45
RN hoursweekends
38.8%
Total nursing turnover
23.1%
RN turnover

How full it usually is: this home is certified for 122 beds and averages 97.0 residents a day — about 80% occupied, or roughly 25 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.43 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 3.47 hrs/resident/day on weekends vs 4.18 on weekdays — 17% thinner on weekends. RN hours go from 0.60 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% 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

13
deficiencies at the latest standard inspection (2026-03-20)
5
at the previous standard inspection (2024-12-13)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-05-22 · 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 observations, interviews, and record reviews, the facility failed to ensure resident environments remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one resident (Resident #1) of 3 residents reviewed for 2-person mechanical lift transfers. The facility failed to ensure CNA A transferred Resident #1 on 01/19/2025 with a mechanical lift per her [NAME] (Notes for CNAs to access in PCC to provide a quick overview of the resident's needs) and her comprehensive plan of care plan. CNA A transferred Resident #1 with a gait belt by herself which resulted in a displaced fracture of her right humeral neck (bone at top of arm that connects to ligament (tough fibrous connective tissue) of shoulder). An Immediate Jeopardy was identified as past noncompliance on 5/21/2025. The IJ began on 1/19/25 and ended on 1/20/25. The facility had corrected the noncompliance before the survey began. This failure could put residents 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 · Past Non-Compliance
  • Immediate jeopardy · Jcited before2024-06-27 · 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 observations, interviews, and record reviews the facility failed to ensure each resident the residents environment remained as free of accident hazards as was for 1 of 14 Residents (#16) reviewed for mechanical soft diet needs and supervision. 1.The facility failed to follow the Speech Language Pathologist's (SLP) recommendations to grind meat for Resident #16's mechanical soft diet, served Resident #16 a ham sandwich, with 2 slices of ham lunch meat, each doubled in half; Resident was found shortly after unresponsive, received Cardio Pulmonary Resuscitation (CPR), was sent to the hospital via Emergency Medical Services (EMS) where she died due to a Difficult airway with lots of debris as quoted by the physician. An Immediate Jeopardy (IJ) was identified on 06/23/2024. While the IJ was removed on 06/27/2024, the facility remained out of compliance at a scope of isolated with risk for harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions.…

    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 before2026-05-01 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 5 residents (Residents #1) reviewed for infection prevention measures. CNA A provided care for Resident #1 who had a need for an indwelling urinary catheter and was under Enhanced Barrier Precautions (EBP, an infection control measure in nursing homes requiring staff to wear gowns and gloves during high-contact care for residents at risk of spreading multidrug-resistant organisms) and did not wear any Personal Protection Equipment (PPE). This failure could place residents at risk for infections. Findings included: A record review of Resident #1s admission record, dated 4/30/2026, revealed an admission date of 1/1/2026 with diagnoses including chronic kidney disease (a long-term, progressive condition where…

    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 · E2026-03-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    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 need respiratory care were provided such care, consistent with professional standards of practice for 2 of 2 residents (Resident #91 and Resident #117) and in 1 of 1 oxygen storage rooms reviewed for respiratory care. 1. Resident #91's nasal cannulas for oxygen and BiPAP (bilevel positive airway pressure) mask were not covered in a plastic bag when they were not used on 03/17/2026. 2. The facility failed to ensure Resident #117's oxygen concentrator was set to 2 to 3 liters per minute as ordered by the physician on 03/17/2026 and 03/18/2026. 3. Stored oxygen was not separated -1 oxygen cylinder that was empty was in the full area. 1 oxygen cylinder that was empty was in the full side. This failure could place residents at risk of illness, respiratory complications and accidents. The findings included:3. Observation on 3/18/2026 at 9:19 AM in the oxygen cylinder room, revealed 15 oxygen tanks. There was 1 oxygen…

    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 · E2026-03-20 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record 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 out of 2 medication rooms (500-hall medication room), 2 out of 5 medication carts (500-hall B nursing cart and 500-hall A nursing cart), and 2 of 7 residents (Residents #52 and #155) reviewed for pharmacy services. 1. There was one box of refresh plus eye drop lubricant 50 vials that expired 01/2026 found inside the 500-hall medication room on 03/18/2026. 2. There was one bottle of Mucinex 600 mg guaifenesin extended-release that expired 12/09/2025 found inside the 500-hall B nursing cart on 03/18/2026. 3. There was one insulin lispro injection pen of Resident #52 that was opened on 02/09/2026 found inside the 500-hall A nursing cart on 03/18/2026. 4. MA-I took Resident #55's blood pressure and failed to notify the charge nurse of the low…

    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 · E2026-03-20 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete for 1 of 6 residents (Resident #105) and the facility failed to safeguard medical record information against loss, destruction, or unauthorized use for 1 of 4 halls (hall#8000), reviewed for Administration. 1. The facility failed to ensure Resident #105's wound care physician visits and notes were documented in the resident's EHR prior to or after the resident's discharge on [DATE]. 2. The facility failed to ensure the Medical Records room/Staff break room was closed and kept private and secure. These failures could place residents at risk of not receiving appropriate follow up care, decreased continuity of care, and loss or unauthorized use of their medical records.The findings were: 1. Record review of Resident #105's face sheet dated 3/17/26 revealed the resident was a [AGE] year-old male admitted to the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-20 · 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 received services in the facility with reasonable accommodation of resident needs for 1 of 8 residents (Resident #117) who were observed for call light placement. The facility failed to ensure the call light which had been placed on Resident #117's oxygen concentrator was within reach for Resident #117. This deficient practice could place residents at risk of not being able to call for help as needed.The findings included: Record review of Resident #117's face sheet, dated 03/17/2026, revealed she was admitted to the facility on [DATE] with diagnoses which included: carcinoma (cancer) in situation of anus and anal canal, generalized anxiety disorder, muscle wasting and atrophy, not elsewhere classified, multiple sites, unsteadiness on feet, other abnormalities of gait and mobility, need for assistance with personal care, and history of falling.Record review of Resident #117's Quarterly MDS assessment, dated 02/03/2026,…

    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 · D2026-03-20 · 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 observations, interviews and record review the facility failed to ensure the resident had the right to and the facility promoted and facilitated resident self-determination through support of resident choice, including the right to make choices about aspects of his or her life in the facility that are significant to the resident for 1 of 8 (Resident #136) residents in that:Resident #136 was not able to eat in her room, which was her preference.This failure could affects the residents' ability to live a dignified life at facility.The findings: .Record review of Resident #136's admission Record dated 3/18/2026 reflected that she was admitted on [DATE], re-admitted on [DATE] with diagnoses of multiple sclerosis (is a chronic autoimmune disease in which the immune system attacks the protective myelin sheath surrounding nerve fibers in the brain and spinal cord, disrupting communication between the brain and the rest of the body), dysarthria following other cerebrovascular disease (motor speech disorder…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-20 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #156) out of 26 residents reviewed for environmental concerns. Resident #156's toilet seat was dirty with feces, and staff did not flush feces inside the toilet. This failure could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.The findings were: Record review of Resident #156's face sheet, dated 03/20/2026, revealed the resident was an 88-years-old female and admitted to the facility on [DATE] with the diagnoses of muscle weakness, Parkinson's disease (progressive movement disorder of nervous system), and depression (lowering of a person's mood). Record review of Resident #156's admission MDS assessment, dated on 03/20/2026, revealed the MDS assessment was still in progress because the resident was admitted to the facility on [DATE]. Record review of Resident #156's baseline…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-20 · 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 interviews and record reviews the facility failed to ensure the assessment accurately reflected the residents' status for 1 of 8 (Resident #94) residents in that:Resident #94's MDS was not accurate and did not reflect her indwelling catheter.This failure could affect all residents and staff could not know how to provide care to residents.Findings:Record review of Resident #94's admission Record dated 3/20/2026 revealed she was admitted on [DATE] with neuromuscular dysfunction of bladder (refers to what happens when an injury or disease interrupts the electrical signals between your nervous system and bladder function). Record review of Resident #94's consolidated orders for March 2026 revealed she had an order for indwelling foley catheter 16 French (tubing size) for diagnosis of urine retention every shift. May use leg bag while up during day.Record review of Resident #94's Quarterly MDS dated [DATE] revealed she was not marked for have an indwelling catheter.Record review of Resident #94's care plan…

    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 · D2026-03-20 · 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, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #64) of 5 residents reviewed for incontinence care. When CNA-A was providing incontinent and indwelling urinary catheter care to Resident #64 on 03/19/2026, the CNA did not clean the resident's left buttock area. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #64's face sheet, dated 03/20/2026, revealed the resident was a 91-years-old male, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnoses of spondylosis (the natural progression of degenerative changes in the spine that occur with aging), weakness, and neuromuscular dysfunction of bladder (when…

    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 before2026-03-20 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 store food in accordance with professional standards for food service safety. for 1 of 3 (Bluebonnet Hall unit pantry) unit pantries in that:The unit pantry refrigerator was out of range temperature; and the apple juice container was not labeled or dated.This could affect residents that used the unit pantry and place residents at risk for food borne illnesses. The Findings:Observation on 3/18/2026 at 9:13 AM in the Bluebonnet Hall unit pantry revealed the refrigerator temperature was at 42 degrees Fahrenheit. The apple juice container was half full and was not dated or labeled.Observation on 3/18/2026 at 10:18 AM in the Bluebonnet Hall unit pantry revealed the refrigerator temperature was 42 degrees Fahrenheit. The apple juice container was half full and was not dated or labeled.Interview on 3/18/2026 at 10:22 AM with RN E confirmed the Bluebonnet Hall unit pantry refrigerator was at a temperature of 45 Degrees Fahrenheit. RN E stated if refrigerator unit was higher than 42 degrees Fahrenheit, it could cause food…

    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
Show the remaining 16 citations
  • Potential for harm · D2026-03-20 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly, for 1 of 1 dumpster in that:The garbage container did not have a plug at the bottom.This could affect all residents and could cause debris, foul odors and harborage and feeding of pests.Findings include:Observation on 3/17/2026 at 9:45 AM with FSM, observed the dumpster did not have a plug at the bottom.Interview on 3/17/2026 at 9:45 AM with FSM stated he was not aware that the dumpster did not have a plug and will call the city.Record review of policy, Sanitation and infection preventions, solid Waste disposal dated 5/95, reflected, Policies, Food waste and rubbish in the Food and Nutrition Services Department will be disposed of in an approved manner to prevent contamination of food, clean dishes, or clean working areas.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-20 · 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 observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 of 26 residents (Resident #47 and #153) reviewed for infection control practices. 1. RN-G did not put on gloves and a gown when entering Resident #47's room, and Resident #47 was on contact precautions. 2. When LVN-L changed the dressing of Resident #153's gastrostomy tube site, the LVN-L changed her gloves without sanitizing or washing her hands. The deficient practices could place residents at risk for cross contamination and infections.The findings included: 1. Record review of Resident #47's face sheet, dated 03/20/2026, revealed the resident was a [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of periprosthetic fracture around internal prosthetic right hip joint (fracture associated with an orthopedic…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-20 · tag F0943 — isolated
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    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 abuse, neglect and exploitation training and dementia training for 1 of 5 (CNA-M) employees reviewed for training requirements were completed. The facility failed to ensure abuse, neglect and exploitation training was provided to CNA-M. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of the personnel records for CNA-M revealed a hire date of 11/24/2024. Review of training log provided by human resources revealed no evidence that CNA-M received abuse, neglect and exploitation training. Interview with the Staffing Coordinator on 03/20/2026 at 12:04 PM revealed CNA-M was agency staff and not working at the facility anymore since on 01/19/2026, but the facility should have checked if CNA-M completed abuse, neglect and exploitation training or not before the CNA worked on the floor, and if the CNA did not take the training, the facility should have provided the training to the CNA. The Staffing Coordinator said it was her…

    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 · D2025-12-12 · 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 interview and record review, the facility failed to immediately consult the resident's Physician and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status or an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 of 4 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's Physician and notify the resident's Responsible Party of a worsened wound to sacrum. This failure could place residents at risk of delays in decision making, and poor quality of care and life. Findings Include:Record review of Resident #1's face sheet revealed an [AGE] year old male admitted for respite on 12/01/2025. At the time of admission resident had active diagnosis of sequelae of cerebral infarction (commonly known as a stroke), cerebrovascular disease (condition that affects blood flow to the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-13 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 of 6 residents (Resident #146) whose records were reviewed for code status. The facility failed to obtain a DNR order for Resident #146 upon admission, [DATE], based on her Living Will, dated [DATE]. This deficient practice could affect any resident who requested a DNR code status and could result in staff providing CPR for a resident who did not want to be resuscitated. The findings were: Review of Resident #146's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction and unspecified Atrial Fibrillation. Review of Resident #146's Living Will dated [DATE] reflected she did not want cardiac resuscitation. Review of Resident #146's clinical assessment, dated [DATE], did not reflect Resident #146's code status. Review of Resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-13 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were 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 1 of 5 residents (Residents #38) reviewed for reporting allegations of abuse and neglect. CNA C failed to report an incident of suspected abuse, from 11/09/2024, to the abuse and neglect coordinator until 11/11/2024…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-13 · 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 must accurately reflect the resident's status for 2 of 6 Residents (Resident #48 and Resident #73) whose records were reviewed for assessments. 1. MDS staff failed to include Resident #48 was diagnosed with Major Depressive Disorder on her most recent quarterly MDS assessment, dated 9/22/24. 2. MDS staff failed to include Resident #73 was diagnosed with Major Depressive Disorder, Post Traumatic Stress Disorder on his most recent quarterly MDS assessment, dated 10/18/24. This deficient practice could affect any resident and could result in Residents not receiving needed care and services. The findings were: 1. Review of Resident #48's face sheet, dated 12/10/24, revealed she was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke) and unspecified Dementia. Review of Resident #48's Care Plan, revised on 9/23/24, revealed Resident #48 was scheduled for a psychological evaluation on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-13 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program for 2 of 6 Residents (Resident #48 and Resident #73) whose records were reviewed. 1. The facility failed to refer Resident #48 to the stated-designated authority after she was diagnosed with Major Depressive Disorder (MDD). 2. The facility failed to refer Resident #73 to the stated-designated authority after he was diagnosed with Major Depressive Disorder (MDD), Post Traumatic Stress Disorder. This deficient practice could affect a resident with a new onset diagnosis of mental disorder, intellectual disability, or a related condition and could result in residents not receiving needed care and services for identified psychiatric problems. The findings were: 1. Review of Resident #48's face sheet, dated 12/10/24, revealed she was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke) and unspecified Dementia. Review…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-13 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 6 Residents (Resident #48 and Resident #73) whose records were reviewed. 1. MDS staff failed to include Resident #48 was diagnosed with Major Depressive Disorder (MDD), that she received Sertraline (anti-depressant) and was receiving psychiatric services on her most recent Care Plan, revised 9/23/24. 2. MDS staff failed to include Resident #73 was receiving psychiatric services for diagnoses including Major Depressive Disorder (MDD) and Post Traumatic Stress Disorder (PTSD) on his most recent Care Plan revised on 10/7/24. This…

    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 · D2024-11-15 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to assess a resident using the quarterly review instrument specified by the state and approved by CMS not less frequently than once every 3 months for 1 (Residents #1) of 18 residents reviewed for quarterly MDS assessments. The facility failed to complete a quarterly MDS for Resident #1 with the ARD of 10/10/2024. This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information for care plans. Findings included: Record review of Resident #1's face sheet, dated 11/15/2024, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (brain disorder that slowly destroys memory and think skills), paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), heart failure (heart muscle does not pump blood as well as it should), muscle wasting and atrophy…

    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 · D2024-06-07 · 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 ensure all drugs and biologicals, in accordance with State and Federal laws, were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 3 residents (Resident #2) reviewed for storage of drugs. The facility failed to ensure Resident #2's medications were secured. This failure could place residents at risk of medication misuse and diversion. Findings include: Record review of Resident #2's admission Record, dated 6/4/24, reflected the resident was initially admitted to the facility on [DATE]. Resident #2 had diagnoses which included: Right femur fracture, Muscular Dystrophy (disease that causes weakness and loss of muscle mass), Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs),…

    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 before2023-11-17 · 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 revealed the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for meal service. Dietary staff stacked 12 trays on a food cart filled with multiple individual servings of lemon cake which were exposed to the elements in the kitchen. This deficient practice could contribute to the spread of foodborne illnesses and make the residents sick. The findings were: Observation and interview in the kitchen on 11/14/23 at 11:46 AM revealed 3 Dietary Staff preparing lunch trays. Further observation revealed a cart with 12 trays filled with 6 to 8 slices of lemon cake on individual plates next to the steam table. The food cart was not covered. Interview with the DM revealed the dietary staff prepared the food cart with the desserts. He stated one food cart with desserts had already been delivered to one of the resident halls. The DM stated it would take staff about 1 hour to prepare meal trays and distribute all lemon cakes. He stated the cart was…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 3 of 4 Residents (#35, #51 and #75) reviewed for accident hazards. The water temperature at the bathroom sink exceeded the safe water temperature of 110 degrees for Resident's #35, #51 and #75. 1. The water temperature in Resident #35's bathroom was 119 degrees. 2. The water temperature in Resident #51's bathroom was 115 degrees. 3. The water temperature in Resident #75's bathroom was 118 degrees. This deficient practice could place residents at risk for avoidable skin burns. The findings were: Review of the facility water temperature checks log from 11/8/23 to 11/14/23 revealed the temperature in the unit where Resident #35, #51 and #75 residents read 110+. 1. Review of Resident #35's face sheet, dated 11/17/23, revealed she was admitted to the facility on [DATE] with diagnoses including unspecified Dementia mild ( group of symptoms that affects…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-17 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review revealed the facility failed to ensure a comprehensive care plan was revised by the interdisciplinary team after the quarterly review assessments were completed for 2 of 8 Residents (#51 and #66) whose care plans were reviewed. 1. Resident #51's revised Care Plan did not address her ADL deficits and the level of assistance she required for all ADL's. 2. Resident #66's revised Care Plan did not reflect Resident #66's used corrective lenses for adequate vision. These deficient practice could contribute to residents not receiving required care identified in their MDS assessment. The findings were: 1. Review of Resident #51's face sheet, dated 11/17/23, revealed she was admitted to the facility on [DATE] with diagnoses including anxiety disorders (persistent and excessive distress that affects daily life) and cognitive communication deficit (difficulties with communication that have an underlying cause in a cognitive deficit more than a language or speech deficit).…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-03 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 1 of 2 staff (LVN B) reviewed for infection control, in that: LVN B took a stack of PPE gowns enclosed with a plastic wrap on the outside and handed them to another person on the outside the door of Unit 6 ([NAME]) without following infection control procedures when removing items from a isolation/quarantine area. These failure could place residents at risk for cross contamination. The findings included: Observation on 11/02/2023 at 7:38 a.m. revealed LVN B in a green gown come from behind the nurses station carrying a stack of PPE Gowns enclosed in plastic wrap and open the entrance door and handed from the quarantine area to the outside door to another staff member on the outside door who then took the PPE gowns and placed them on the clean PPE cart.…

    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
  • No harm found · B2026-03-20 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 within 14 days after a facility completes a resident's assessment to transmit encoded, accurate, and complete MDS data to the CMS System for 5 of 14 residents (Residents #62, # 86, #107, #123, and #132) reviewed for MDS transmission. 1. Residents #62, #107, #123, and #132's, discharge MDS assessments were not transmitted within 14 days of completion. 2. Resident #86's admission MDS assessment on 03/20/2026 was not completed and not transmitted within 14 days since the resident was admitted to the facility on [DATE]. This deficient practice placed residents at risk of not having completed assessments and not having appropriate care. The findings were: 1. Review of Resident #62's face sheet, dated 03/19/2026, revealed an admission date of 11/05/2025 with diagnoses which included: fracture of unspecified part of right clavicle (a long, slightly curved bone that connects your arm to your body), subsequent encounter for fracture with routine…

    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

“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

$45,130 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $22,925 — penalty dated 2025-05-22
  • $22,205 — penalty dated 2024-06-27
  • Medicare payment denial — starting 2024-08-01 for 19 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
GUADALUPE COUNTY HOSPITAL BOARDOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF100%since 05/01/2021
GANN, KODYIndividualCORPORATE OFFICERsince 05/01/2021
EDEN HOME INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2021
CARPENTER, WENDYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/04/2026
CALDERON, GUIDOIndividualADP OF THE SNFsince 06/04/2026
HUBER, SUZANNEIndividualADP OF THE SNFsince 09/23/2024

CMS files one row per role, so the 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$21.2M
Net patient revenuemost recent cost report
-108.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 40%Medicare 15%Other / private 45%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$1,559per resident / day
operating cost
$47,399per month
≈ monthly operating cost
$747per 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 455618. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-20, 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