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Sundance Inn Health Center

2034 Sundance Parkway, New Braunfels, TX 78130 · For profit - Corporation · 128 certified beds · (830) 221-1400 Medicare & Medicaid certified

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Flagged for abuse2 immediate-jeopardy citations$6,364 in federal fines
Insights

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

Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0602, F0607) — most recent Aug 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $6,364 in federal fines (most recent 2025-08-03)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)

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

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

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

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2020 Sundance Pkwy · (830) 625-7748 · Call to confirm hours
Pharmacy
18 Gruene Park Dr · (830) 387-4914 · Call to confirm hours
Grocery
1641 Hunter Rd · (830) 627-9087 · Call to confirm hours
Park
Place of worship
2171 Common St · (830) 625-3969

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 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 increased6.0%15.8%15.4%better
Long-stay residents who lose too much weight0.6%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better 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 injury4.9%3.3%3.3%worse
Long-stay residents whose ability to walk worsened4.4%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication8.0%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers1.4%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control21.5%13.4%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table9.6%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 vaccine100.0%88.0%79.4%better
Short-stay residents rehospitalized after admission27.9%25.7%22.6%worse
Short-stay residents with an outpatient ER visit9.9%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days3.062.171.67worse
Long-stay outpatient ER visits per 1,000 resident days2.162.061.80worse

* 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.

59.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 256 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.7%U.S. median 51.5%
Got home and stayed home
9.0%U.S. median 10.7%
Went back to hospital
47.2%U.S. median 56.6%
Met the expected recovery
0.56U.S. median 0.31
Therapy hours / resident / day
0.25hours / resident / day
Physical therapy
0.25hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 47.2% 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 180 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 0.56 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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 SNF59.7%CMS range 53.6–65.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.0%CMS range 7.0–11.910.7%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 discharge47.2%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 discharge33.3%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 discharge39.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.6%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 stay0.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.2%CMS range 3.6–9.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.131.02Oct 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

0.52
RN hours/ resident / day
1.14
LPN hours/ resident / day
1.92
Aide hours/ resident / day
3.58
Total nurse hours/ resident / day
0.23
RN hoursweekends
47.1%
Total nursing turnover
27.3%
RN turnover

How full it usually is: this home is certified for 128 beds and averages 87.7 residents a day — about 69% 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 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 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 2.96 hrs/resident/day on weekends vs 3.84 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.63 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as 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

6
deficiencies at the latest standard inspection (2025-08-28)
4
at the previous standard inspection (2024-06-27)

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.

27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.

  • Immediate jeopardy · J2025-08-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 4 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when CNA A allegedly physically and verbally assaulted her on 07/28/2025. An IJ (Immediate Jeopardy) was identified on 08/02/2025. The IJ began on 08/02/2025 and was removed on 08/03/2025. The facility took action to remove the IJ before the abbreviated survey began; however, all staff had not been trained on staff-to-resident abuse prevention. The IJ template was provided to the facility on [DATE] at 04:53 p.m. and signed by the ED. While the IJ was removed on 08/03/2025, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective…

    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
  • Immediate jeopardy · J2025-08-03 · 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 Base of observations, record reviews and interviews 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 1 of 4 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when CNA A allegedly physically and verbally assaulted her on 07/28/2025. An IJ (Immediate Jeopardy) was identified on 08/02/2025. The IJ began on 08/02/2025 and was removed on 08/03/2025. The facility took action to remove the IJ before the abbreviated survey began; however, all staff had not been trained on staff-to-resident abuse prevention. The IJ template was provided to the facility on [DATE] at 04:53 p.m. and signed by the ED. While the IJ was removed on 08/03/2025, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm due to the facility's need 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 · Ecited before2026-04-30 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand, the facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman and the facility failed to provide the notice of transfer or discharge required at least 30 days before the resident is transferred or discharged or provide notice as soon as practicable before transfer for 3 of 3 residents (Residents #1, #2, and #3) reviewed for Discharge Rights.The facility failed to give the representative of Resident #1 written documentation at least 30 days prior to discharge which informed them of the facility-initiated decision to discharge the resident and the right to appeal.The facility failed to give the representative of Resident #2 written documentation at least 30 days prior to discharge which informed them of the facility-initiated…

    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 before2026-04-17 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 1 resident (Residents #1) reviewed for medical records. The facility failed to ensure Resident #1's medication consent form was completed on the most recent consent for antipsychotic or neuroleptic medication treatment for Seroquel (an atypical antipsychotic used to treat schizophrenia, bipolar disorder, and major depressive disorder) and available in the resident's medical record. This deficient practice could place residents at risk of delayed or improper care due to inaccurate medical records.The findings include: 1. Record review of Resident #1's admission record revealed a female admitted on [DATE] with diagnoses that included metabolic encephalopathy, acute respiratory failure with hypoxia, bipolar disorder, and insomnia. Record review of Resident #1's discharge MDS, dated [DATE], revealed the resident's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-28 · 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 observation, interview, and record review, the facility failed to immediately inform or consult the physician and the resident's representative when there was a need to alter treatment for one (Resident #8) of three residents reviewed for physician notifications.1. The facility failed to ensure MA X and nursing staff alerted the physician that Resident #8 missed 7 doses of ear drop medication on 08/22/25 at 9:00 AM, 12:00 PM, 5:00 PM, 9:00 PM and 08/23/25 at 9:00 AM, 12:00 PM, 5:00 PM.2. The facility failed to ensure LVN G notified the physician that Resident #8 had missed 2 doses of ear drop medication on 08/28/25 at 9:00 AM and 12:00 PM.This failure placed residents at risk of a delay in treatment, and a worsening of their condition.Findings included:Record review of Resident #8's Quarterly MDS assessment, dated 06/30/25, revealed Resident #8 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident #8 had moderate cognition impairment with a BIMS score of 8. Resident #8…

    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 before2025-08-28 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 a resident had a discharge summary that included, but not limited to a recapitulation of the resident's stay, that included but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultant results and a final summery of the resident's status to include items, at the time of the discharge that was available to release to authorized persons and agencies, with the consent of the resident or resident's representative for 1 of 3 residents (Resident #92) reviewed for discharge summary.The facility failed to complete a discharge summary for Resident #92.This failure could place residents at risk of not having complete records after permanent discharge from the facility. Findings included:Record review of Resident #92's Discharge MDS Assessment, dated 06/28/25, reflected Resident #92 was a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #92 had diagnoses which included…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-28 · 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 interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #12) of 8 residents reviewed for care plans. The facility failed to include Resident #12's PTSD (Post Traumatic Stress Disorder) in his care plan. This failure could place the residents at risk of not receiving services to meet their needs. Findings included: Record review of Resident #12's admission MDS, dated [DATE], reflected the resident was admitted to the facility on [DATE] with diagnoses which included stroke, Diabetes, and (PTSD). Resident #12 had a BIMS score of 14, indicating he was cognitively intact. Record review of Resident #12's care plan, dated 8/8/25 reflected he had no intervention for his PTSD. In an interview 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 · D2025-08-28 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received foot care that was consistent with professional standards of practice and treatment to prevent complications from conditions such as diabetes and assisting residents in making necessary appointments with qualified healthcare providers such as podiatrists and arranging transportation for 1 (Resident #7) of 10 residents reviewed for foot care. The facility failed to provide Resident #7 assistance with foot care leaving his toenails to be about an inch long on both feet. This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection.Findings included:Record review of Resident #7's Quarterly MDS assessment, dated 06/30/25, revealed Resident #7 was a [AGE] year-old male admitted on [DATE]. Resident #7 had cognition intact with a BIMS score of 11. Resident #7 was dependent on staff for shower/baths. Active diagnoses included Diabetes Mellitus (high blood sugar),…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-28 · 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 menu was followed for one of one meal (lunch on 08/27/25) reviewed for food and nutrition services. The facility failed to ensure the menu was followed for the lunch meal on 08/27/25 by providing the pureed trays with lemon pudding for dessert and the regular trays with a cherry cream cheese swirl brownie for dessert. This failure could place residents at risk of weight loss, altered nutritional status and diminished quality of life.Findings included:Record review of the facility's menu, dated 08/27/25, reflected for Wednesday (08/27/25) the following: Lunch-Open Face [NAME] Sandwich, Breaded Corn Nuggets, Marinated Vegetable Salad, Cherry Cream Cheese Swirl Brownie. Observation on 08/27/25 at 10:35 AM revealed that the [NAME] pureed rye bread, the [NAME] sandwich ingredients (pastrami, sour kraut, cheese, and thousand island dressing), creamed corn, and the vegetables. No cherry cream cheese brownie was pureed or served 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-28 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #8) of 3 residents reviewed for accuracy of medical records. The facility failed to ensure Resident #8's missed doses of ear drops was documented accurately and completely on 08/22/25 and 08/23/25. This failure could place the residents at risk for incomplete and inaccurate clinical records which could lead to miscommunication or a delay in services.Findings included: Record review of Resident #8's Quarterly MDS assessment, dated 06/30/25, revealed Resident #8 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident #8 had moderate cognition impairment with a BIMS score of 8. Resident #8 required supervision or touching assistance by staff for personal hygiene and partial assistance for shower/bathing. Resident #8 had adequate hearing reflecting no difficulty in…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #1) reviewed for ADL care. The facility did not provide showers or baths to Resident #1 as scheduled and requested on 07/26/2025. This failure can affect residents by decreasing their quality of life. The findings included: Record review of Resident #1's admission Record, dated 07/30/2025, reflected Resident #1 was admitted on [DATE] and discharged on 07/29/2025. Resident #1 was noted to be [AGE] years old. Record review of Resident #1's EMR Medical Diagnosis tab, undated and accessed 07/30/2025, reflected Resident #1 was diagnosed with rhabdomyolysis (a condition that causes skeletal muscle to break down rapidly which can result in muscle pain and kidney injury), dorsalgia (back pain), and morbid (severe) obesity (overweight or excess body fat). Record…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-03 · 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 interview and record review the facility failed to ensure that the resident's environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #2) whose environment was reviewed for safety hazards. Nursing staff failed to properly discard and remove a syringe used for insulin (a hormone essential for individuals with insulin insufficiency, such as diabetics, to convert food into energy and maintain blood sugar levels) administration from Resident #2's room. This deficient practice could affect residents exposed to syringes and could contribute to avoidable accidents.The findings included: Record review of Resident #2's admission Record, dated 07/30/2025, reflected Resident #2 was admitted on [DATE] and discharged on 07/29/2025. Resident #2 was noted to be [AGE] years old. Record review of Resident #2's EMR Medical Diagnosis tab, undated and accessed 07/30/2025, reflected Resident #2 was diagnosed with cerebral infarction (a disruption in the brain's blood flow), fracture…

    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
Show the remaining 15 citations
  • Potential for harm · D2025-06-09 · 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 observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 1 nursing treatment carts out of 3 nursing carts reviewed for storage. The facility failed when on 06/09/2025 the nursing treatment cart was left unlocked and unattended by the Treatment Nurse when she entered the room to wash her hands and when wound care was provided to Resident #3. This failure could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. The findings included: Record review of Resident #3's admission Record (Facesheet), dated 06/09/2025, revealed he was admitted to the facility on [DATE] with diagnosis which included heart failure, high blood pressure, and open wound of right toes. Record review of Resident #3's Physician Order Summary Report, revealed an order for Povidone-Iodine Solution 10% apply to 2nd toe topically every day shift with a start date of 05/23/2025. Record…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-11 · 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 interview, record review, and observation, the facility failed to ensure residents have a right to personal privacy for 1 of 4 resident (Resident #2) reviewed for privacy, in that: CNA C and CNA D did not completely close Resident #2's privacy curtain while providing incontinent care on 4/11/25. This failure could place residents at-risk of loss of dignity due to lack of privacy. The findings included: Record review of Resident #2's face sheet, dated 04/11/2025, revealed an admission date of 04/06/2025, with diagnoses which included: Non traumatic acute subdural hemorrhage (bleeding between the layers surrounding the brain), Dysphagia (difficulty swallowing), Malignant neoplasm of prostate (prostate cancer), Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension (high blood pressure), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #2's Cognitive and Swallowing assessment dated [DATE], revealed the resident had a…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-11 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 residents (R#8) reviewed for misappropriation of resident property. The facility failed to ensure that Resident #8 was not subject to financial misappropriation or exploitation from Housekeeper E from the time period 11/10/2024 to 11/11/2024. Housekeeper E accepted a check for $350 from Resident #8. This deficient practice was determined to be Past Non-Compliance from 11/10/2024 to 11/11/2024, due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure had the potential to affect the residents in the facility by placing them at risk for misappropriation of resident property. The findings included: Record review of Resident #8's face sheet dated 11/11/2024 revealed the resident was a [AGE] year-old male admitted on [DATE] and discharged [DATE]. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-04-11 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 of 8 residents (Resident #8) reviewed for abuse, neglect, exploitation, or mistreatment and report to one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. The facility failed to report to a law enforcement entity of an allegation of exploitation on 11/10/2024, where Housekeeper E received a check in the amount of $350 from Resident #8. This failure had the potential to affect the residents in the facility by placing them at risk for exploitation and/or misappropriation of resident property. The findings included: Record review of Resident #8's face sheet dated 11/11/2024 revealed the resident was a [AGE] year-old male…

    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 before2025-04-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure environment remains as free of accident hazards as is possible; for residents for 1 of 8 units (unit 800) observed for environment, in that: 1. The facility failed to ensure potential hazards Clorox (disinfecting wipes) were locked up and kept out of resident rooms. This failure could place residents at risk of a diminished quality of life due to an unsafe environment. The findings included: Review of Resident #1's face sheet dated 04/09/2025, revealed an admission date of 10/04/2024 with diagnoses which included: Hydrocephalus (Buildup of fluids in the brain), Dementia (decline in cognitive abilities), Hypertension (high blood pressure), Type 2 diabetes mellitus (high level of sugar in the blood), Anxiety disorder (A group of mental illnesses that cause constant fear and worry). Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 00, indicating he was severely impaired. Review 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-27 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 5 residents (Residents #86) reviewed for dignity. The facility failed to ensure the urinary collection bag for Resident #86's catheter was covered with a privacy bag. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings include: Record review of Resident #86's face sheet, dated 06/27/2024, revealed a [AGE] year-old male admitted to the facility on [DATE] had diagnoses which included hypertension (blood is pumping with more force than normal through your arteries), gastroesophageal reflux disease (condition in which the stomach contents move up into the esophagus), acute kidney failure (when your kidneys suddenly become unable to filter waste products from your blood), muscle weakness (lack of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-27 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 1 of 6 residents (Resident #18) who were reviewed for accommodation of needs. The facility failed to ensure Residents #18's call lights were placed within their reach. This failure could place dependent residents at risk of injuries and unmet needs. Findings included: Review of Resident #18's undated face sheet reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of congestive heart failure (a condition that develops when your heart doesn't pump enough blood your body needs), urinary tract infection, generalized anxiety, unspecified falls, and legal blindness. Record review of Resident #18's care plan dated 06/07/24 reflected Resident #18 had a risk for falling. The approach on the risk for falling care plan was to remind resident to call for assistance before…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-27 · 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 implement a comprehensive care plan to meet the resident's highest practicable physical, mental, and psychosocial well-being of 1 (Resident #30) of 6 residents reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #30's active wounds to right heel, left foot second toe, and a contracted right hand. This failure could place residents of risk for not receiving appropriate care and treatment, lack of skin/wound interventions, a delay in treatment, a decline in health, and hospitalization. Findings included: Record review of undated face sheet reflected Resident #30 was an [AGE] year-old male admitted to the facility on [DATE]. Resident #30 had the following diagnoses of hemiplegia following cerebral infarct right dominate side (paralysis following a stroke), dysphagia (difficulty swallowing), type 2 diabetes (elevated blood Pressure), contracture of muscle, Peripheral Vascular Disease…

    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 · D2024-06-27 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure residents were free of significant medication errors for 1 (Resident #42) of 6 residents reviewed for medication errors in that: The facility transcribed a medication (hydralazine a medication used to treat high blood pressure) be given oral for a resident who was to receive her medications per her gastrostomy tube. The failure could cause residents who receive medications by gastrostomy tube at risk for aspiration and related complications. The findings included: Review of Resident #42's undated face sheet reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Hemiplegia following cerebral infarct affecting the right dominate side (paralysis of the right side), essential hypertension (high blood pressure) , dysphagia (difficulty swallowing), and gastrostomy status (meaning the resident has a stomach tube in abdomen in which she received nutrition and medications). Review of Resident #42's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-31 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 1 resident (Resident #1) reviewed for infection control, in that: While providing incontinent care for Resident #1, CNA A touched the trash can with her bare hands and did not wash her hands before putting her gloves on and starting to provide care. CNA B did not sanitize or wash her hands in between change of gloves. These failures could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #1's face sheet, dated 05/30/2024, revealed an admission date of 03/10/2023, with diagnoses which included: Spondylolysis (Bony defect or stress fracture in the arch of a vertebra), Chronic respiratory failure (condition making it difficult to breath), Fibromyalgia…

    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 · F2023-04-20 · 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 in the facility's only kitchen. 1. The facility failed to ensure food items in the refrigerator and freezer were dated, labeled, and not expired. 2. The facility failed to ensure dishes and cookware were washed in the dishwasher with the appropriate sanitation procedures. These failures could affect residents by placing them at risk for food-borne illness. Findings include: 1. Observation and interview on 04/18/23 at 8:28 AM with the Dietary Manager (DM) revealed the following food items in the refrigerator, as identified by the DM: - Three containers of ranch dressing, with one opened and used. All three containers had an expiration date of March 2023. - One container of Ken's chicken dipping sauce, opened 03/23/23 with an expiration date of July 2022. - One bag of dill, undated, unlabeled, and exposed to air. - One bottle of cocktail sauce, opened 04/06/23 with a printed label from US foods on top 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-20 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one Staff (CNA A) of three staff observed caring for a COVID positive resident and one staff (MA B) of three staff observed during medication pass for infection control in that: 1. CNA A failed to wear the recommended PPE when answering a call light for Resident #15, a COVID positive resident on isolation. 2. MA B failed to prevent contamination of the cap and eyedrop bottle for Resident #33. MA B cross-contaminated her medication cart by placing Resident #33's eye drop bottle, and nasal spray box on her bedside table then into the cart. MA B Used contaminated gloves to place eye drops into Resident #17's eyes. MA B Failed to use proper hand hygiene before administering each residents' medications. MA B failed to…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-20 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that re to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident # 71) of twenty residents reviewed for care plans. The facility failed to develop a comprehensive care plan to address Resident # 71's oxygen via nasal canula and bipap machine use which was being administered by the facility. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: Review of Resident # 71's face sheet, dated 4/20/23, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), chronic and acute…

    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 before2023-04-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one resident (Residents #69) of three residents reviewed for ADL care. The facility failed to ensure Residents #69 was provided showers as scheduled. These failures could place residents at risk of not receiving personal care services and of having a decreased quality of life. The findings include: Review of Resident #69's face sheet , dated 04/20/23, revealed a [AGE] year-old woman, admitted to the facility on [DATE] with diagnoses of acquired absence of left and right leg above the knee, Type 2 Diabetes Mellitus, chronic kidney disease, glaucoma (a group of eye conditions that can cause blindness), age related nuclear cataract (opacification and coloration in the center of the lens and a major cause of blindness), major depressive disorder, recurrent, and anxiety disorder. Review of Resident #69's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for one of four residents (Resident # 71) reviewed for respiratory care. The facility failed to ensure Resident # 71 had physician orders for oxygen via nasal canula which was administered by the facility. The facility failed to ensure Resident # 71 had physician orders for bipap machine (a type of ventilator that helps people with respiratory disease breath during sleep) which was administered by the facility. The facility failed to ensure Resident # 71's oxygen humidifier was changed weekly per facility policy. These failures could affect residents by causing residents who required respiratory care to have a diminished quality of life and complications with respiratory care. Findings included: Review of Resident # 71's face sheet,…

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

    Quality of Life and Care 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

$6,364 in federal fines across 1 penalty.

  • $6,364 — penalty dated 2025-08-03

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

Part of a chain

This home belongs to CANTEX CONTINUING CARE — 37 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.1-1.1 vs chain
Health inspection 2 of 52.9-0.9 vs chain
Staffing 2 of 51.9+0.1 vs chain
Quality measures 4 of 54.3-0.3 vs chain
The other 36 homes this chain runs (chain average 3.1★, per CMS)
1 of 5The Carlyle at Stonebridge ParkSouthlake, TX 1 of 5The Colonnades at Reflection BayPearland, TX 1 of 5The CrescentSugar Land, TX 2 of 5Ashford GardensHouston, TX 2 of 5Magnolia ManorGroves, TX 2 of 5Palomino PlaceMesquite, TX 2 of 5Park Valley Inn Health CenterRound Rock, TX 2 of 5San RemoRichardson, TX 2 of 5SorrentoSan Antonio, TX 2 of 5The Villa At Mountain ViewDallas, TX 2 of 5Windemere At Westover HillsSan Antonio, TX 2 of 5Windsor GardensLancaster, TX 3 of 5Bel Air at TeravistaRound Rock, TX 3 of 5Fort Bend Healthcare CenterRosenberg, TX 3 of 5HollymeadFlower Mound, TX 3 of 5LarkspurLufkin, TX 3 of 5Mill CreekSilsbee, TX 3 of 5Prairie EstatesFrisco, TX 3 of 5Renaissance Care CenterGainesville, TX 3 of 5Solera at West HoustonHouston, TX 3 of 5The Bradford At BrooksideLivingston, TX 3 of 5The Broadmoor at Creekside ParkThe Woodlands, TX 3 of 5The Harrison at HeritageFort Worth, TX 3 of 5The Manor at SeagovilleSeagoville, TX 4 of 5Beacon HillDenison, TX 4 of 5CarraraPlano, TX 4 of 5Oakwood Manor Nursing HomeVidor, TX 4 of 5The Belmont At Twin CreeksAllen, TX 4 of 5The Madison on MarshCarrollton, TX 4 of 5Woodville Health And Rehabilitation CenterWoodville, TX 5 of 5Bonne ViePort Arthur, TX 5 of 5Coronado At Stone OakSan Antonio, TX 5 of 5Crestview CourtCedar Hill, TX 5 of 5Laurel CourtAlvin, TX 5 of 5Palma RealMathis, TX 5 of 5Riverside OaksVictoria, TX

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

Who owns this facility

Owner / managerTypeRoleSince
HOOPER, GRADYIndividualCORPORATE OFFICERsince 12/01/2015
COMAL HEALTH CARE CENTER LTD. CO.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/04/2025
POMEROY, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2020

CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$11.7M
Net patient revenuemost recent cost report
+9.5%
Operating marginrevenue minus expenses
$1
Related-party expense0% of expenses
Who pays — share of resident-days
Medicaid 42%Medicare 26%Other / private 33%

This home reported $1 paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$312per resident / day
operating cost
$9,491per month
≈ monthly operating cost
$345per 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 676472. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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