Olney Rehabilitation And Care Center
1402 W Elm, Olney, TX 76374 · For profit - Corporation · 99 certified beds · (940) 564-5631 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 improved from 1 to 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.2% | 15.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 4.3% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.3% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 0.8% | 0.8% | 2.0% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.8% | 2.4% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 5.3% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 17.0% | 14.0% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 29.0% | 18.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 94.7% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.7% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 10.9% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.3% | 9.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 19.0% | 1.5% | 1.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.59 | 2.17 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.90 | 2.06 | 1.80 | worse |
‡ 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.
Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 24% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 6.2–16.5 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | not 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 discharge | not 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 discharge | not 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 identified | not 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 setting | not 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 discharge | not 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 stay | not 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 worsened | not 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 hospitalization | not 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 SNFs | 1.33 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 99 beds and averages 35.3 residents a day — about 36% occupied, or roughly 64 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 3.16 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.61 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 2.84 hrs/resident/day on weekends vs 3.29 on weekdays — 14% thinner on weekends. RN hours go from 0.42 to 0.32 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%. 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
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.
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.
20 citations, most serious first. The 10 most serious are shown; the remaining 10 are one tap away and print in full.
- Potential for harm · Fcited before2025-12-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 1 of 1 kitchen, in that: 1. The wooden cabinet doors beneath the handwashing sink did not close completely. 2. The high-temperature dish machine did not work properly and was not being used. 3. The dietary staff were manually washing the resident use eating utensils, beverage glasses, coffee cups, the pots, pans, mixing bowls, cooking utensils and serving utensils in a two-compartment sink.4. The dietary staff did not document water temperatures and bleach sanitizer levels for the two-compartment sink.5. Floor tiles were missing beneath the high temperature dish machine.6. Wooden shelf units and cabinet had scraped surfaces and peeling paint with the porous wooden surfaces exposed and not sealed.7. Shelf liner was used to cover wooden shelves in the paper supply room and the shelves were soiled with food crumbs and dust beneath…
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.
- Potential for harm · F2025-12-11 · tag F0908 — failed to keep essential equipment working — widespreadKeep 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 ensure the maintenance of mechanical and electrical equipment in safe operating condition in 1 of 1 kitchen, in that:The low temperature dish machine was not operating and was not being used to wash and sanitize the resident use eating utensils, beverage glasses, coffee cups, and the food preparation pots, pans, mixing bowls, cooking utensils, and serving utensils. This failure placed the residents at risk for foodborne illness and a decline in health status from being served food that had been prepared with pans and utensils that had not been properly sanitized. The findings included: Observation on 12/09/2025 at 9:50 AM revealed a high temperature dish machine was located in the facility kitchen. The manufacturer recommendations were for minimum water temperatures at 160 degrees F for washing and at 180 degrees F for rinsing. The dish machine was not in use at the time of the observation. In an interview on 12/09/2025 at 9:50 AM, 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.
- Potential for harm · D2025-12-11 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure 1 Quarterly MDS (Minimum data set) Assessment and 1 Significant Change MDS Assessment was encoded, accurate, complete, and electronically transmitted to the CMS (Center for Medicare & Medicaid Services) system for 2 of 6 residents (Resident #1 and Resident #12) whose MDS records were reviewed. The facility did not ensure the Quarterly MDS assessment was completed and electronically transmitted as required for Resident #1. The facility did not ensure the Significant Change MDS assessment was completed and electronically transmitted as required for Resident #12. These deficient practices placed residents at risk for not being assessed for current functional status and changes in condition to develop or revise a plan of care to meet their needs.The findings included: 1. Record review of Resident #1's face sheet accessed on 12/11/2025 revealed the resident was an [AGE] year old female admitted on [DATE] and readmitted on [DATE] with diagnoses that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure assessments accurately reflected the health status for 2 of 14 residents (Residents #13 and #27) whose MDS assessments were reviewed, in that:1. Resident #13 had a physician order for insulin to be administered one time weekly on Monday per a sliding scale. Her MDS documented she received insulin injections daily.2. Resident #27 had a physician order for an antiplatelet medication. Her MDS assessments documented she received an anticoagulant medication. This failure placed residents at risk for not receiving care and services to meet their physical needs.The findings included: Review of the Resident #13's admission Record, dated 12/11/2025, documented a [AGE] year-old-female admitted to the facility on [DATE]. The record documented the resident's diagnoses included type 2 diabetes mellitus (a chronic condition when the body cannot use insulin properly resulting in high blood sugar levels). Review of Resident #13's Order Summary Report documented…
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.
- Potential for harm · E2024-09-12 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 interviews and record review the facility failed to ensure that residents were free of a med error of 5% or greater (7.69%) 2 of 6 residents who reviewed for medication errors . 1. The facility failed to ensure LVN A primed (removing air bubble to ensure that the needle is open and working) insulin pen for Resident #35 before administering Fiasp (insulin aspart) 2. The facility failed to ensure LVN B primed the insulin pen for Resident #37 before administering Fiasp (insulin aspart). 3. The facility had a 7.69% medication error rate based on 2 errors out of 26 opportunities, which involved 2 of 6 reviewed for pharmacy services. This failure placed resident at risk of increased doses of medications. The findings included: During an observation on 09/10/2024 at 11:23 AM LVN B administered Fiasp flex touch pen (insulin) 22 units to Resident #35 without priming the flex touch pen prior to administration. Review of Resident # 35's electronic face sheet revealed [AGE] year-old female admitted…
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.
- Potential for harm · Ecited before2024-09-12 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with current accepted professional principles for 2 (West Hall Medication Cart and Treatment Cart) of 3 carts observed for medication storage. The facility did not ensure [NAME] Hall Medication Cart and Treatment Cart were locked and secure. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them. Findings included: Observation on 9/10/24 at 7:16 AM revealed treatment cart parked in [NAME] hallway corner near bathroom with a resident within 6 feet away of open, unsecured cart. No nurse in sight of cart. Present in cart were medicated dressings, prescription ointments and creams, over the counter creams. In an interview on 09/10/2024 at 7:18 AM L VN B stated that both LVNs had keys to treatment cart and it was both responsibility to ensure cart was secure. LVN B further stated the cart should be locked if not in use or sight of nurse and failure to secure cart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-09-12 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 1 of 1 kitchen, in that: A. floors were swept and free from dirt and food crumbs. B. bottom shelves were clean. The facility's failure could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status. The findings included: On 09/10/24 beginning at 6:40 AM, during the initial tour of kitchen, revealed refrigerator #1 had spilled, dry milk on the bottom in multiple areas, and underneath the shelves. In the corners and against the wall, there were dust and food crumbs. In the kitchen area, the floor was dirty with dirt and food crumbs and trash underneath the shelves and along the walls. In a follow-up interview and observation of the kitchen on 09/10/24 at 9:00 AM, there was no change in the soiled floors. In refrigerator #1, there was dry spilled milk in multiple areas and food crumbs underneath the shelves and along the bottom. The cleaning…
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.
- Potential for harm · Dcited before2024-09-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (Resident #4) resident reviewed for infection control practices, in that: LVN C failed to perform hand hygiene and change gloves as appropriate while providing incontinence care for Resident #4. This failure could place resident's risk for cross contamination and the spread of infection. Findings included: Review of Resident #4's face sheet, dated 09/12/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia (memory loss), urinary tract infection, obesity (overweight) and depression (feeling of sadness). Review of Resident #4's Minimum Data Set (MDS) assessment dated on 07/26/24, revealed Resident #4 required dependence (helper does all effort) with most…
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.
- Potential for harm · D2024-05-31 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 2 residents reviewed for quality of care (Resident #1). The facility failed to ensure the nurses initialed and dated wound dressings when wound care was performed on Resident #1. This failure could result in residents with wounds of not having their treatments performed as ordered, wounds becoming infected wounds, and decreased wound healing. Findings include: Record review of face sheet dated 5/29/24 indicated Resident #1 was a [AGE] year-old female admitted initially to the facility on 5/4/17 and re-admitted on [DATE] with diagnoses including TYPE 1 Diabetes (an autoimmune disease that originates when cells that make insulin are destroyed by the immune system), TYPE 2 Diabetes (high blood sugar, insulin resistance, and lack relative lack of insulin), Anemia (blood disorder in which 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.
- Potential for harm · Fcited before2023-08-04 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that: 1. The range was soiled with a built up, sticky grease like substance. 2. There were soiled wet towels and food crumbs on the floor. 3. There were dead crickets in standing water in the drain underneath the dishwasher an in the clean handwashing sink. 4. The commercial refrigerator contained one half of a watermelon covered in saran wrap and not dated, an opened block of butter was open to the refrigerator air and not dated or covered by an airtight container, an open plastic container of brown gravy dated 7/20, ½ water melon not dated and covered with saran wrap and an undated zip lock baggie of cut onions. 5. The Dietary Manager touched meat with her bare hand and placed it on the steam table with the meat served to residents 6. Metal piping directly above range and over vent hood covered in grease 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.
Show the remaining 10 citations
- Potential for harm · E2023-08-04 · tag F0637 — patternAssess the resident when there is a significant change in condition
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 complete a comprehensive assessment within 14 days after a significant change in the physical condition for 3 of 7 residents (Residents #11, #26 and #27) whose records were reviewed for assessments after significant change. The facility failed to complete a comprehensive MDS assessment after Resident #11 and Resident #27 had a significant weight loss. The facility failed to complete a comprehensive MDS assessment after Resident #26 returned from the hospital and had a significant decline. These failures placed residents at risk of having assessment that do not reflect significant changes in their conditions and need for additional care/treatment. The findings included: Resident #11 Review of Resident #11's face sheet revealed Resident #11 was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnoses of heart failure, chronic respiratory failure, chronic obstructive pulmonary disease (a group of lung diseases that block air…
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.
- Potential for harm · Ecited before2023-08-04 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to complete an assessment that accurately reflected the resident's status for 6 of 17 residents (Residents #'s 11, 16, 27, 29, 35, and 36) whose records were reviewed for MDS accuracy, in that: The facility failed to ensure Resident #11's most recent Annual MDS Assessment reflected a significant weight loss. The facility failed to ensure Resident #16's reflected the usage of a wheelchair harness under restraints. The facility failed to ensure Resident #27's Quarterly MDS accurately reflected her significant weight loss. The facility failed to ensure Resident #29's MDS documented the last attempt for a GDR. The facility failed to ensure Resident #35's MDS accurately reflected her weight loss. The facility failed to ensure Resident #36's admission MDS accurately reflected his mood status. These failures by the facility placed residents at risk of not receiving the care and services to meet their needs. Findings included: Resident #11 Review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-04 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a base line care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident within 48 hours of the resident's admission for 6 of 15 residents (Resident #s 7, 16, 26, 27, 35 and 36) whose records were reviewed for baseline careplans, in that: 1. Resident #7 did not have a base line care plan developed and implemented or reviewed by an RN following admission to the facility on [DATE]. 2. Resident #16 did not have a base line care plan developed and implemented or reviewed by an RN following admission to the facility on [DATE]. 3. Resident #26 did not have a base line care plan developed and implemented or reviewed by an RN following admission to the facility on [DATE]. 4. Resident #27 did not have a base line care plan developed and implemented following admission to the facility on [DATE]. 5. Resident #35 did not have a base line care plan developed and implemented 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.
- Potential for harm · E2023-08-04 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive care plan within 7 days after completion of the comprehensive assessment for 9 of 15 residents (Resident #7, Resident #11, Resident #16, Resident 18, Resident #22, Resident #26, Resident #27, Resident #35, and Resident #36) whose records were reviewed for assessments and care plans timing., as well as having an IDT team present at the care conference. The facility failed to ensure that Resident #7, Resident #11, Resident #16, Resident #18, Resident #19, Resident #22, Resident #26, Resident #35, and Resident #36 had care plan developed and updated within 7 days following the completion of the MDS as well as having an Intradisciplinary Team present at the care conference. This failure could place residents at risk of not have having their care plans completed accurately and timely and having the appropriate staff involved in the decision making for their care Findings included: Resident #7- Record review of Resident #7's face…
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.
- Potential for harm · Ecited before2023-08-04 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #22) of two residents reviewed for infection control techniques in that: 1. CNA B did not wash her hands or conduct any hand hygiene practices after passing our trays, touching her hair and assisting other residents before feeding Resident #22. This deficient practice could affect residents and could result in cross contamination and infections. The findings were: Record review of Resident #22's face sheet revealed resident was a [AGE] year-old female who was admitted to the facility 01/30/2020 and a readmit date of 12/09/2022. Resident #22 had diagnoses which included Parkinson's (disorder of the central nervous system that affects movement causing tremors), Bipolar (mental disorder that results in mood swings), Hypertension (high blood pressure), Major Depressive Disorder…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-04 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to coordinate the assessment of one Resident, (Resident #7) of three residents with the pre-admission screening and resident review (PASRR) program, of resident assessments reviewed for PASRR evaluations. The facility did not identify Resident #7 as having mental illness with a primary diagnosis of dementia that would require a PASRR 1012 form or a new PL1 form. This failure could affect residents with psychiatric diagnoses who may not be evaluated for PASRR services and place them at risk of not receiving services for care and treatment. The findings were: Review of Resident #7's Face Sheet and Orders dated 08/04/2023 revealed he a was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7's diagnoses included: dementia (thought process that interferes with daily function), delusional disorder (altered reality), psychotic mood disorder (mental condition that causes you to lose touch with reality, main symptoms are…
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.
- Potential for harm · D2023-08-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 was provided such care, consistent with professional standards of practice for 1 2 of 4 residents (Resident #11 and Resident #17) reviewed for respiratory orders in that: Resident #11 did not have her oxygen flow rate set at 2 liters per continuously as ordered by her physician. Resident #17 had her nebulizer mask that was not bagged and left lying on her nightstand uncovered. This these deficient practices could affect the residents who used oxygen and nebulizer treatments and could result in residents receiving incorrect or inadequate respiratory support and could result in a decline in health. The findings were: Resident #11 An observation and interview of Resident #11 on 08/01/2023 at 10 AM revealed Resident #11 sitting in her recliner with her light out and her feet and legs elevated in her chair had her O2 nasal cannula in her nostrils. and Tthe O2 tubing was dated, but the oxygen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-04 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review facility failed to maintain an accurate record of the disposition of all controlled drugs and failed to destroy medications for destruction in that: DON failed to count and sign off on the medication sheets before they were put in storage for destruction. The facility failed to do a final count for the following controlled medications- Hydrocodone-Acetaminophen 10-325 (QTY 23), Clonazepam 0.5 MG (QTY 8), Hydrocodone-Acetaminophen 5-325MG (QTY 40) These failures could place the residents at risk of losing their medications in a drug diversion which could result in delayed healing. Findings Include: During an observation and interview on 08/03/2023 at 1:25 PM with the DON, revealed 3 controlled medication packs which contained Hydrocodone-Acetaminophen 10-325 (QTY 23), Clonazepam 0.5 MG (QTY 8), Hydrocodone-Acetaminophen 5-325MG (QTY 40) in the Controlled Substance cabinet in the DON's office was a cabinet that they put discontinue controlled medications that were set to be destroyed. The DON revealed that she was given the medication…
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.
- Potential for harm · Dcited before2023-08-04 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews the facility failed to ensure drugs and biological used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory cautionary instructions, and the expiration date when applicable for 1 of 1 medication rooms. The Medication Room had expired and discontinued medication and biologicals. This failure could the residents who resided in the facility at risk of receiving expired medications Findings included: During an observation on 08/01/2023 at 10:41 AM, the medication room cabinet contained a box of Albuterol Sulfate Inhalation Aerosol prescribed to Resident #33 . The medications had been dispensed on 04/25/2022 with a discard by date of 04/25/2023. During an interview on 08/01/2023 at 11:00 AM with the DON, revealed that it was expired, and it should have been thrown out when they did their weekly audit of the medications . She revealed that she was responsible for ensuring it was completed. She revealed that they must have just missed it. She stated that this failure could…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-04 · tag F0801 — isolatedEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to conduct the functions of the food and nutrition service for 1 of 1 (DM) reviewed for qualified dietary staff. The facility failed to ensure the facility's DM met the requirements for a certified dietary manager. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses. Findings included: Record review of the DM's employee file revealed a hire date o 02/10/2016 There was no documented evidence of a Dietary Manager Certificate found in the file. In an interview on 8/03/2023 at 10:30M the DM stated she did not have her dietary manager certification. She stated she did not think it was still a requirement for the dietary manager to be certified . She stated she did have a current food handlers' certificate. In an interview on 08/03/2023 at 2:00 PM the administrator stated she had been employed at the facility for 4 months, she stated it was her expectation that the Dietary…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| OLNEY-HAMILTON HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 10/01/2014 |
| SIEGERT, STASHA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | — | since 01/01/2022 |
| HUFF, MICHAEL | Individual | CORPORATE DIRECTOR | — | since 10/01/2014 |
| SABATER, CHRISTOPHER | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2024 |
| OLNEYTX LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/19/2025 |
| JOHNSON, JEREMY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2024 |
| PFEIFER, MARY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/19/2025 |
| MISTRETTA, CASSANDRA | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 03/18/2026 |
CMS files one row per role, so the 13 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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
Straight from this home’s Medicare cost report (CMS, FY2024). 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
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.
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 455611. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, 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.