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Focused Care at Odessa

2443 W 16th St, Odessa, TX 79763 · For profit - Corporation · 75 certified beds · (432) 333-2904 Medicare & Medicaid certified

Call the home — (432) 333-2904 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jan 20261 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
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
  • it has 1 actual-harm citation
  • 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
  • its payroll-based staffing rating is low (1/5)

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2450 W Loop 338 · (432) 332-2695 · Call to confirm hours
Pharmacy
2443 W 16th St · (432) 333-2904 · Call to confirm hours
Grocery
1613 N County Rd W · (432) 332-1521 · Call to confirm hours
Park
1015 N County Rd W · (432) 368-3548 · 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

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 3 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased21.4%15.8%15.4%worse
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 infection1.4%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%2.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.7%3.3%3.3%worse
Long-stay residents whose ability to walk worsened9.8%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication6.9%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers4.3%3.8%4.7%typical
Long-stay residents with worsening bladder/bowel control4.2%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.5%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%88.0%79.4%better

* 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.

46.5% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.5%U.S. median 51.5%
Got home and stayed home
11.8%U.S. median 10.7%
Went back to hospital
0.27U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 31% 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 SNF46.5%CMS range 34.8–63.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.8%CMS range 8.0–15.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.071.02Oct 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

0.32
RN hours/ resident / day
0.79
LPN hours/ resident / day
1.96
Aide hours/ resident / day
3.06
Total nurse hours/ resident / day
0.18
RN hoursweekends
45.9%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 75 beds and averages 54.7 residents a day — about 73% occupied, or roughly 20 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 3.06 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.96 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 2.55 hrs/resident/day on weekends vs 3.27 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.37 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% 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

6
deficiencies at the latest standard inspection (2026-01-08)
6
at the previous standard inspection (2024-10-03)

Deficiencies are unchanged from the previous inspection. 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 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2025-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents environment remained as free of accidents and hazards as possible, and each resident received adequate supervision to prevent accidents for 1 (Resident #7) of 5 residents reviewed for transfers. The facility failed to ensure Resident #7 had floor mat at bedside when in bed to prevent falls with injury that occurred on 05/12/2025. This failure could place residents at risk for falls or injuries. Findings included: Record review of Resident #7's face sheet dated 5/14/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: cerebrovascular disease, meaning he has problems with blood flow in the brain, which can lead to strokes or damage to brain tissue; seizures, which are sudden episodes of uncontrolled electrical activity in the brain that can cause shaking or confusion; psychotic disorder caused by a medical condition, meaning he may have false beliefs or see things…

    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 · E2026-05-27 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working 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 observation, interview, and record review, the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition for 1 of 1 laundry room reviewed for physical environment. The facility failed to maintain the clothes washers in working condition. This failure placed residents who relied on the facility for laundry services improperly cleaned clothes and diminished quality of life. Findings included:Review of Resident #1's admission Record, dated 5/21/26 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (kidney no longer works the way it needs to). Resident #1 was on dialysis. Review of Resident #1's Quarterly MDS Assessment, dated 5/20/26 revealed:She had a BIMS score of 15 of 15 (indicating her cognition was intact) and showed no signs of delirium.She needed supervision or cueing for most ADLs. In an observation and interview on 5/21/26 at 9:20 a.m. the Laundry Supervisor stated…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-27 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring and administering of all medications to meet the needs of 1 of 5 (Resident #1) residents reviewed for pharmacy services in that: MA A failed to ensure Resident #1 took her medications at the time of administration and left them on the bed side table. This failure could place residents at risk for medication overdose, medication under-dose, drug diversion, and not receiving therapeutic doses of prescribed medications. The findings included:Review of Resident #1's admission Record, dated 5/21/26 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (kidney no longer works the way it needs to). Resident #1 was on dialysis. Review of Resident #1's Quarterly MDS Assessment, dated 5/20/26 revealed:She had a BIMS score of 15 of 15 (indicating her cognition was intact) and showed no…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-08 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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 observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 set of window blinds in room [ROOM NUMBER] and 1 of 1 resident smoking areas. 1. The facility failed to ensure the blinds were not broken.2. The facility failed to ensure adequate cleaning in the designated smoking area. These failures placed the staff, residents, and visitors at risk of living, working and visiting in an unsafe, unsanitary, and uncomfortable environment. Findings include: Observation on 01/06/2026 at 10:04 AM revealed the blinds were broken in room [ROOM NUMBER]. Both Bed A and Bed B were occupied and not interviewable. Observation on 01/07/2026 at 10:05 AM revealed the ground around the outside patio and the ground of the smoking area was littered with smoked cigarette butts. During an interview on 01/08/2026 at 11:05 AM with the Administrator, she stated there was not a policy for cleaning the smoking area.…

    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 · Ecited before2026-01-08 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety.1. The facility failed to discard cabbage in a box dated 12/8/2025, containing brown and rotted leaves, in the reach-in cooler.2. The facility failed to ensure an opened bag of grits in the dry storage room was properly sealed and dated.These failures could place residents at risk for food borne illness.The findings included:1. Observation on 1/6/2026 at 9:00 AM in the reach-in cooler revealed 2 boxes of raw cabbage with a label indicating it was received on 12/8/2025. The box was opened, and cabbage was visible; approximately 25% of the cabbage leaves had turned black or were rotten.2. Observation on 01/6/2026 at 9:15 AM in the dry storage room revealed a bag of grits on a rack. The bag had been opened and was rolled over. The bag was not sealed or placed in a sealed bag or container. There was also no open date on the grits.During an interview on 01/6/2026 at 9:10 AM, the 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
  • Potential for harm · D2026-01-08 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 interviews, the facility failed to ensure residents were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment for 1 resident (Resident #2) of 3 residents reviewed for informed consents.The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Resident #2 prior to administering an increased dose of Seroquel, a psychotropic medication (a psychoactive drug taken to exert an effect on the chemical make-up of the brain and nervous system).This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the benefits and risks of the medications prescribed.Findings Included:Record review of Resident #2's admission Record, dated 01/08/2026, revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses which…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-08 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 4 resident (Resident #13) reviewed for privacy, in that: CNA A and CNA B did not completely close Resident #13's window blinds while providing incontinent care and a change of clothes for the resident. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.The findings include: Record review of Resident #13's admission record dated 01/08/2026 revealed she was admitted to the facility on [DATE] with diagnosis of dementia, muscle wasting and atrophy. She was [AGE] years of age. Record review of Resident #13's MDS assessment dated [DATE] revealed: Cognitive Skills for Daily Decision Making = Severely impaired - never/rarely made decisions. Bladder and bowel = Urinary Continence - Frequently incontinent. Bowel continence = Always incontinent. Record review of the current care plan for Resident #13, last reviewed/revised: 01/07/2026, revealed 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-08 · 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 interview and record review, the facility failed to ensure allegations of abuse were reported immediately, but not later than 2 hours after the allegation was made to the State Agency for 1 of 4 residents (Resident #20) reviewed for abuse in that: The facility did not report to the State Survey Agency that Resident #20 reported an allegation of abuse to the administration within 2 hours of the incident. This deficient practice could place residents at risk for not having all allegations of abuse and neglect reported to the State Survey Agency in a timely manner.Findings Include: Record review of Resident #20's admission record dated 01/07/2026 revealed he was admitted to the facility on [DATE] with diagnosis of Parkinson's disease, schizophrenia, muscle wasting and atrophy. He was [AGE] years of age. Record review of Resident #20's MDS assessment dated [DATE] revealed in part: BIMS = 5 indicating severe impairment. Mobility devices wheelchair. Functional abilities - Chair/bed-to-chair transfer: 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 · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-08 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to have nursing staff with appropriate competencies to provide nursing and related services to assure resident safety and attain/maintain the highest practicable well-being of each resident for 1 of 1 nursing staff reviewed for nursing services. The facility did not provide evidence that LVN E was competent and received training on resident care plans and implementing care according to care plans.This failure could place the residents at risk for not receiving required care, complications, injury, hospitalization, and decline in conditionFindings included:During an interview on 1/7/2026 at 3:20PM LVN E stated she did not know how to read care plans. LVN E stated she had not received training in reading or implementing care plans. LVN E stated she had worked at the facility for 7 years. LVN E stated she knew the care plans were located in Point Click Care. LVN E stated the risk of not knowing how to read care plans could result in improper care and not meeting resident needs.During an interview on 1/7/2026 at 3:10 p.m., 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-04 · tag F0940 — failed to train staff — pattern
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 5 of 27 (CNA A, CNA B, LVN C, CNA D, and LVN E) employees reviewed for disaster training requirements. CNA A, CNA B, LVN C, CNA D, and LVNE were not adequately trained in emergency preparedness training related to bomb threats. This failure could result in delayed or inappropriate response in the event of a bomb threat.The findings included:Resident #3Review of Resident #3's admission Record, dated 12/2/25, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including paraplegia, pressure ulcer to the sacral region, neuropathy and above the knee amputation of both legs. Resident #3 was discharged [DATE]. Review of Resident #3's Quarterly MDS, dated [DATE], indicatedHe had a BIMS score of 13 of 15 (indicating he was cognitively intact) and he showed no signs of delirium.He reported no symptoms of depression.There were no…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-18 · 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 observations, interviews, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 6 (Residents #6, #7, #8, #9, #10, and #11) of 6 residents observed for oxygen management. The facility failed to ensure that Residents on oxygen (#6, #7, #8, #9, #10, and #11) had oxygen signs posted outside their bedrooms (Rooms 4, 14, 15, 20, 26, and 33). This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings included: Resident #6Record review of Resident #6's admission record dated 10/10/25, revealed an admission on [DATE] and re-admission on [DATE] to the facility. The admission record revealed, a [AGE] year-old male diagnosed with heart failure and respiratory failure. Record review of Resident #6's MDS dated [DATE], revealed a BIMS score of 3, indicating the resident had severely impaired cognition. The MDS 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · E2025-05-14 · tag F0644 — pattern
    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 interviews, and record review, the facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #4) of 3 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health. Findings included: Record review of Resident #4's face sheet dated 5/13/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: contracture of an unspecified joint (a joint that has become stiff and difficult to move) and contracture of muscle, unspecified site (a tightening of muscles that limits movement); generalized muscle weakness (overall reduced strength throughout…

    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 before2025-05-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #6) residents reviewed for infection control. The facility failed to ensure Resident #6 had a contact isolation on her door alerting visitors she was in isolation related to shingles. This failure could place residents at risk of cross contamination which could result infections or illness. Findings include: Record review of Resident #6's face sheet dated 5/13/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: seizures, including those caused by fever, and has episodes of uncontrolled body shaking without a clearly identified cause; poor coordination, which affects her ability to move steadily and may lead to clumsiness or difficulty walking; aphasia, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-14 · 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 interview and record review the facility failed to report an alleged violation of injury of unknown origin immediately to the administrator of the facility and to other officials (including to state survey agency) in accordance with State law and according to their policy for 1 (Resident # 3 ) of 2 residents reviewed for allegations of abuse. The facility failed to report Resident #3 's allegation of abuse related to LNV C's alleged withholding of medication to State Office. This failure could place all residents at risk for abuse and/or neglect by not immediately reporting allegations of abuse to the proper authorities at the facility. Findings Include: Record review of Resident #3's face sheet dated 5/14/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of generalized anxiety, schizophrenia, and bipolar disorder. Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, indicating his cognition was intact. Record 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-14 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 residents were provided, based on the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored activities and individual activities, designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident for 1 of 5 (Resident #4) residents reviewed for activities. The facility failed to provide regular, individualized activities to Resident #4. This failure placed residents at risk of decreased physical, mental, and psychosocial well-being. Findings included: Record review of Resident #4's face sheet dated 5/13/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: contracture of an unspecified joint (a joint that has become stiff and difficult to move) and contracture of muscle, unspecified site (a tightening of muscles that limits movement); generalized muscle weakness…

    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 · D2025-05-14 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident, who was fed by enteral means, received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #6) reviewed for enteral feeding. The facility failed to ensure Resident #6's head of bed was maintained at 30 degrees elevated while receiving continuous feeding. This failure could place residents at risk of aspiration (when food or liquid goes into the lungs or airway). Findings included: Record review of Resident #6's face sheet dated 5/13/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: seizures, including those caused by fever, and has episodes of uncontrolled body shaking without a clearly identified cause; poor…

    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 · D2025-05-14 · 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 medical records on each resident that are accurately documented for 1 (Resident #7) of 6 residents reviewed for accuracy of records. The facility failed to ensure LVN C documented Resident #7's return from the hospital. This failure could have placed residents at risk for inaccurate medical records. Findings included: Record review of Resident #7's face sheet dated 5/14/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: cerebrovascular disease, meaning he has problems with blood flow in the brain, which can lead to strokes or damage to brain tissue; seizures, which are sudden episodes of uncontrolled electrical activity in the brain that can cause shaking or confusion; psychotic disorder caused by a medical condition, meaning he may have false beliefs or see things that aren't real due to brain-related illness; substance dependence in remission, indicating a past drug or…

    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 · Fcited before2024-10-03 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure: Food that was beginning to rot (discoloration and had rotten smell) was discarded. Staff knew how to check the sanitizer level in the dishwasher. Staff knew how to wash their hands. Food was dated per the facility's policy. Food was not stored on the floor. The dry storage and refrigerator were clear of debris and food under the shelves. These failures could affect residents who received meals prepared from the kitchen at risk for food borne illness and cross contamination. Findings included: Initial observation on 10/1/24 beginning at 9:05 a.m. of the facility's only kitchen revealed: The refrigerator revealed: the bananas in the refrigerator were simultaneously green and brown and the sandwich snacks were not dated. The dry storage revealed: food debris including an apple were under the shelves; 13 boxes of canned goods were on the floor;…

    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 · E2024-10-03 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to treat residents with respect, dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 13 of 13 residents in the confidential group interview. Staff used cell phones in residents' presence causing residents to feel disrespected and ignored. Staff had residents sit at assigned seating in the dining room. Staff labeled resident's clothing in large print over their clothing. These failures could result in a diminished quality of life for the identified residents and could affect additional residents by causing a loss of self-esteem and increased isolation. The findings included: Observations on 10/1/24 at 10:06 a.m. during initial rounds revealed Resident #9 (unsampled) was in a wheelchair in his room. His t-shirt was labeled in black marker about 2 inches wide. In an interview on 10/1/24 at 10:47 a.m. Laundry Aide I said sometimes family members labeled the shirts and sometimes the housekeepers had to do it. Laundry Aid I said they would go up and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-03 · 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 each resident received adequate supervision and assistance devices to prevent accidents for 3 of 5 residents (Residents #17, #18 and #51) reviewed for transfers and supervision in that: Nursing staff and Resident #17's doctor were not aware Resident #17 had his right leg secured to his footrest with a gait belt. CNA A transferred Resident #18 from his bed to his wheelchair by taking him from his under arms. CNA G and CNA H transferred Resident #51 from his wheelchair to his bed taking him from under his arms and by the back of his pants. These failures could put residents at risk of accidents and serious injuries which could result in a reduced quality of life. Findings included: Resident #17 Review of Resident #17's admission Record dated 10/2/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke, hemiplegia of the right side, and convulsions. Review of Resident #17's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-03 · 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 communicable diseases and infections for 3 (Resident #18, Resident #41 and Resident #20) of 6 residents reviewed for incontinent care in that: CNA A failed to change her gloves after they became contaminated and wash or sanitize her hands in between glove change while assisting Resident #18 with incontinent care. CNA B failed to change their gloves after they became contaminated while assisting Resident #41 and Resident #20 with incontinent care. These failures could place resident's risk for cross contamination and the spread of infection. Finding included: RESIDENT #18 Record review of Resident #18's admission record dated 10/01/24 indicated he was admitted to the facility on [DATE] with diagnoses of dementia, unsteadiness on feet, reduced mobility, and muscle…

    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 before2024-10-03 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #17) reviewed for care plans in that: The facility failed to ensure there was a care plan in place for Resident #17's ankle enabler. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Review of Resident #17's admission Record dated 10/2/24 revealed he was a was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke, hemiplegia of the right side, and convulsions. Review of Resident #17's Quarterly MDS assessment dated [DATE] revealed: He had a mental status score of 3 of 15 (indicating severe cognitive impairment). He was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-03 · 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 for 2 (Resident #20, Resident #41) of 6 residents observed for oxygen management. The facility failed to ensure Oxygen was ordered for both Resident #20 and Resident #41. This failure could place residents at risk of not receiving appropriate respiratory care. The findings were: Resident #41 Record review of Resident #41's admission record dated 10/02/2024 indicated the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The admission record revealed the resident had diagnoses that includes end stage renal disease, Type 2 diabetes mellitus, muscle weakness, and heart failure. Record review of Resident #41's MDS dated [DATE] revealed a BIMS score of 15 indicating resident was cognitively intact. There was no indication of oxygen use in the MDS. Record Review of residents #41's order…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews the facility failed to ensure 1 of 6 residents (Resident #1) received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing. The facility failed to ensure Resident #1's four wound dressings were dated and initialed per facility policy. This deficient practice could affect residents who received pressure ulcer preventative treatments and place them at risk for skin breakdown, infection, pain, and a decline in health. The findings include: Record review of Resident #1's face sheet, dated 04/11/24, revealed an [AGE] year-old male, admitted to the facility on [DATE]. Diagnoses included Urinary Tract Infection (bladder infection), Type 2 Diabetes Mellitus with Hyperglycemia (high blood sugar), and Congestive Heart Failure (the heart cannot supply enough blood to meet your body's needs). Record review of Resident #1's Order Summary Report, dated 04/11/24,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-29 · tag F0656 — failed to write and follow a full care plan — pattern
    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 Resident #4 FTag Initiation Resident #41 FTag Initiation Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 12 residents (Residents #4, #8, #11, #57) reviewed for care plans in that: 1. The facility failed to ensure Resident #4 had a care plan in place to address her cognitive status or pain management. 2. The facility failed to ensure Resident #8 had a care plan in place to address her delirium or the decline in her behavioral status. 3. The facility failed to ensure Resident #11 had a care plan in place to address his ADL status. 4. The facility failed to ensure Resident #57 had a care plan in place to address his use of hospice services. This failure could affect residents by placing them at risk of not receiving individualized care and services…

    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 · E2023-08-29 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for 4 of 4 medication carts at the nurses station reviewed for medication storage in that: 1. The facility failed to ensure LVA A secured the medication carts when they were left unattended. 2. The facility failed to ensure LVN B secured the treatment cart when it was left unattended. These failures could place residents at risk for drug diversion or accidental ingestion. Findings included: During an observation on [DATE] at 11:00 AM 4 medication carts and a treatment cart were all seen unlocked and unattended at the nurses station. Inside the cart were several medication packets and pill bottles, wound care supplies and scissors. During an observation on [DATE] at 11:50 AM, the treatment cart was seen unlocked and unattended for approximately 7 minutes. The DON walked by twice and failed to notice the unlocked unattended cart. Inside the cart were several medications, ointments, and…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #11) of 12 residents reviewed for quality of care. The facility failed to document or communicate that the resident was removing his tube feedings during feeding times. This resulted in Resident #11 not receiving his full recommendation of prescribed formula. This failure placed residents at risk of decline and weight loss. Findings included: Review of Resident #11's admission Record, dated 08/29/23, revealed the resident was an [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses including dementia, moderate protein calorie malnutrition, Type 2 Diabetes, and Gastrostomy status (feeding tube). Review of Resident #11's admission MDS assessment, dated 07/22/23, revealed: He had a mental status of 7 of 15 (this indicated…

    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 before2023-08-29 · 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 control program designed to prevent the development and transmission of infections for 2 of 4 residents (Resident #16 and #61) reviewed for infection control. 1.CNA C failed to perform hand hygiene appropriately while providing incontinent care for Resident #16. 2.CNA D failed to perform hand hygiene appropriately while providing incontinent care for Resident #61. These failures could place residents at risk for transmission of diseases and organisms. The findings included: Review of Resident #16's Resident Face Sheet dated 08/29/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus, hypertension (high blood pressure), peripheral vascular disease (circulatory condition where narrowed blood vessels reduce blood flow to the limbs), chronic atrial fibrillation (irregular heart rate caused by poor blood flow), stage 3 kidney disease (mild 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

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to FOCUSED POST ACUTE CARE PARTNERS — 25 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 51.9+0.1 vs chain
Health inspection 3 of 52.1+0.9 vs chain
Staffing 1 of 51.2-0.2 vs chain
Quality measures 3 of 54.0-1.0 vs chain
The other 24 homes this chain runs (chain average 1.9★, per CMS)

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
MIDLAND COUNTY HOSPITAL DISTRICTOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2017
BOWERMAN, STEPHENIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICERsince 01/01/2023
CHAPLIN, CARIIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2025
FLORES, THOMASIndividualMANAGING CONTROL - GOVERNING BODYsince 05/01/2023
GOLDAPP, SHANNONIndividualMANAGING CONTROL - GOVERNING BODYsince 11/01/2024
GREENE, TRACIEIndividualMANAGING CONTROL - GOVERNING BODYsince 04/01/2017
GRIMES, DAVIDIndividualMANAGING CONTROL - GOVERNING BODYsince 04/01/2017
MCKENZIE, MARKIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2017
FOCUSED POSTOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/25/2025
FOCUSED POST ACUTE CARE PARTNERS II LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/25/2025
FOCUSED POST ACUTE CARE PARTNERS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/25/2025
FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/25/2025
FPACP ODESSA LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/25/2025
AKINJAGUNLA, SUNKANMIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/03/2024
CONLEY, SHAWNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2017
MELENDEZ, LEONELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/31/2024
STRUBBE, LORETTAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2017
WADE, DLISAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/16/2017
LE, CHAUIndividualADP OF THE SNFsince 11/01/2017

CMS files one row per role, so the 33 rows in the source record cover these 19 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.

6 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.

$5.5M
Net patient revenuemost recent cost report
+1.0%
Operating marginrevenue minus expenses
$272K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 76%Medicare 9%Other / private 14%

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $272K 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

$249per resident / day
operating cost
$7,561per month
≈ monthly operating cost
$251per 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 675751. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, 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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