Pearsall Nursing and Rehabilitation Center
169 Medical Dr, Pearsall, TX 78061 · Non profit - Corporation · 150 certified beds · (830) 334-3371 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)
- lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $14,255 in federal fines (most recent 2025-05-09)
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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 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 4 to 5 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 | 20.9% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.2% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.5% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 2.4% | 6.5% | check this* — see note marked star 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 | 1.6% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 16.7% | 14.0% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 41.3% | 18.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.3% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 12.9% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.6% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.7% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 98.0% | 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.
Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 10.2%CMS range 6.4–14.3 | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 1.43 | 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 150 beds and averages 100.7 residents a day — about 67% occupied, or roughly 49 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 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 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 2.92 hrs/resident/day on weekends vs 3.44 on weekdays — 15% thinner on weekends. RN hours go from 0.48 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 27% is below 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
Deficiencies are fewer than at the previous inspection — improving. 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.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · Dcited before2026-07-16 · 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 interviews, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 6 residents (Resident #17) reviewed for resident assessments.The facility failed to ensure Resident #17's MDS assessment dated [DATE] correctly assessed the resident received dialysis treatments.These failures could place residents at risk for inadequate care and services.The findings included:Record review of Resident #17's face sheet dated 7/13/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included diabetes (condition in which the body has trouble controlling the amount of sugar in the blood), hyperlipidemia (too much fat in the blood; high cholesterol), peripheral vascular disease (poor circulation, usually in the legs, because the blood vessels have become narrowed by fatty deposits), chronic kidney disease stage 5 (kidney failure; the kidneys have lost nearly all their ability to filter the blood, and dialysis or 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.
- Potential for harm · D2026-07-16 · 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
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 assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. 1 of 6 residents (Resident #97) reviewed for pharmaceutical services. LVN B did not prime (a safety test used prior to injecting a patient with insulin in which the dosage selector is dialed to waste at least 2 units of insulin and if insulin solution is seen at the tip of the needle it ensures an accurate dose is injected) the insulin pen prior to injecting Resident #97 with insulin. This deficient practice could affect residents who received insulin by a flex pen in the facility by not receiving the intended therapeutic benefit of their medication.The findings included:Record review of Resident #97's face sheet dated 7/16/26 reflected a [AGE] year old male admitted into the facility on [DATE] and re-admitted 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 · D2026-07-16 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
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 provide special eating equipment for residents who needed them and appropriate assistance to ensure that the resident could use the assistive devices when consuming meals for 1 of 1 resident (Resident #24) reviewed for special eating equipment and assistance when consuming meals.The facility failed to ensure Resident #24 received the physician-ordered slow-flow adaptive drinking cup during the noon meal on 07/13/2026.The failure placed Resident # 24 at risk for aspiration and/or aspiration pneumonia.Record review of Resident #24's face sheet dated 06/11/2024 revealed Resident #24 had a diagnosis including dysphagia (medical term for difficulty swallowing) and a history of stroke (a medical emergency that happens when blood flow to part of the brain stops, causing brain cells to die from lack of oxygen).Record review of Resident #24's physician orders dated 06/11/2024 revealed order for slow-flow adaptive drinking cup with fluids.Record review of Resident #24's care plan dated 11/11/2025 revealed the need for…
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 · D2026-07-16 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
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, observation and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Resident #23) reviewed for hospice services, in that: The facility failed to ensure Resident #23's hospice documents including: The hospice election form and the physician certification and recertification of the terminal illness specific to each patient were present in the hospice binder in the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation. Record review of Resident #23's admission Record dated 07/15/26 revealed a [AGE] year old female admitted to facility 04/01/26. Resident #23'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.
- Potential for harm · Dcited before2026-07-16 · 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 and to help prevent the development and transmission of communicable disease and infection for 1 of 5 residents (Residents #97) reviewed for infection control:During the medication pass, the facility failed to ensure LVN B did not touch the water faucet with his bare hand after washing his hands and wiped the rubber seal to Resident #97's insulin pen with an alcohol swab prior to administering insulin.These failures could place residents at-risk for infection due to improper care practices.The findings included:Record review of Resident #97's face sheet dated 7/16/26 reflected a [AGE] year old male admitted into the facility on [DATE] and re-admitted on [DATE] with diagnoses that included acquired absence of left toes, diabetes (condition in which the body has trouble controlling the amount of sugar in the blood),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-05 · 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 resident's status for 1 of 6 Residents (Resident #9) whose MDS records were reviewed for accuracy. Resident #9's Discharge MDS assessment dated [DATE] incorrectly documented the resident was discharged to a Short-term hospital. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #9's face sheet dated 12/03/2017 revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that included: Type 1 diabetes mellitus with ketoacidosis (no insulin with fat burning creating acid buildup), major depressive disorder (persistent feeling of sadness and loss of interest), and anemia (not enough red blood cells to carry oxygen to the lungs). Record review of Resident #9's Discharge MDS assessment, dated 09/26/2025, revealed under section for identification, Discharge Status was coded as being discharged to Short-Term…
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 before2025-05-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #1) of 5 residents reviewed for incontinence care. When CNA-A was providing incontinent care to Resident #1 on 05/23/2025, CNA-A did not clean the resident's buttock area. This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #1's face sheet, dated 05/23/2025, revealed the resident was [AGE] years old male, originally admitted on [DATE], and re-admitted to the facility on [DATE] with diagnoses of dementia (over time destroy nerve cells and damage the brain), bronchitis (inflammation of the lining bronchial tubes), muscle wasting and atrophy (decrease in muscle mass, weakness and tingling 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.
- Potential for harm · Ecited before2025-05-09 · 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 for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to maintain the temperature of reach-in cooler #1 at or below 41 degrees F. 2. The facility failed to ensure a package of pork sausage and a package of sliced salami were discarded by their use-by dates. 3. The facility failed to record the temperature of reach-in cooler #1 on the Refrigerator Temperature Record on 05/08/2025. 4. The facility failed to properly sanitize the compartments of the blender used to puree food for modified diets in accordance with manufacturer's instructions. These failures could place residents at risk for food borne illness. The findings included: 1. Observation on 05/06/2025 at 11:12 AM of reach-in cooler #1 revealed the digital display outside the cooler indicated a temperature of 52 degrees F. Further observation inside the cooler revealed an analogue thermometer indicating a temperature of 51 degrees F. The Dietary Refrigerator…
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 · D2025-05-09 · tag F0655 — isolatedCreate 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 observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #92) of 8 residents reviewed for baseline care plans. The facility failed to include Resident #92's use of antipsychotic medication in his baseline care plan. This failure could result in residents not receiving needed care and treatment. Findings Included: Record review of Resident #92's admission Record dated 05/09/2025 revealed he was a [AGE] year-old man admitted [DATE] with diagnoses which included dementia (general term for loss of memory, language, problem-solving and other thinking abilities) and unspecified psychosis (when a person has trouble telling the difference between what's real and what's not). Record review of Resident #92's entry MDS assessment dated [DATE] revealed a BIMS score of 2 indicating…
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 · D2025-05-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #89) reviewed for care plans: The facility failed to ensure Residents #89's Care Plan reflected he should receive PASRR services. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included: Record review of Resident #89's admission record, dated 5/9/25, revealed a [AGE] year-old male resident was admitted to the facility on [DATE] and readmitted last on 10/1/24 with diagnoses including major depressive disorder, schizoaffective disorder, insomnia, anxiety disorder, 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 14 citations
- Potential for harm · D2025-05-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for 1 of 2 residents (Resident #61) reviewed for pressure injuries. The facility nurse did not provide wound care to Resident #61 on the evening of 05/07/2025 as ordered. This failure could place residents at risk of improper wound management, deterioration in existing pressure injuries, infection, and pain. Findings included: Record review of Resident #61's admission record dated 05/08/2025 revealed he was a [AGE] year-old-man initially admitted on [DATE], and re-admitted on [DATE] with diagnosis which included: Pressure ulcer of sacral region Stage 4 (most severe type of pressure injury, characterized by full-thickness skin loss located at base of spine, just above buttocks). Record review of Resident #61's Quarterly MDS assessment dated [DATE] revealed…
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 before2025-05-09 · 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 observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 3 medication cart (300 Hall medication cart) reviewed for storage of drugs. The Facility failed to provide change direction labels for Resident #86's medication package of sertraline (Sertraline is an SSRI (serotonin reuptake inhibitor) that increases serotonin levels between neurons (nerves) by blocking serotonin from being absorbed.) which had medication order change from 150 mg to 50 mg. This deficient practice could place residents at risk of medication misuse and diversion. The findings were: Observation on 5/8/25 at 08:32 a.m. revealed a package in the 300-hall medication cart contained medication for Resident #86 with a label for 50 mg of sertraline, and instructions to give 1 tab by mouth daily with 100 mg to equal 150 mg. MA J administered 50 mg of sertraline to Resident #86. Record review of Resident #86's physician orders, dated 5/9/25, revealed an order for sertraline 50 mg give 1 tab…
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 before2025-05-09 · 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 establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 of 8 residents (Residents #69 and #45) reviewed for infection control. 1. The facility failed to ensure CNA -G, after completing peri and foley care for Resident #69, did not replace a bed wedge that had fallen on the floor back onto Resident #69's bed without cleaning/sanitizing it first. 2. The facility failed to ensure RN I changed his gloves and sanitized his hands after removing an old bandage and placing a new bandage, while performing peg tube (an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) site care for Resident #45. These failures could place residents at risk for cross contamination…
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 · E2024-03-29 · tag F0552 — patternEnsure 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 observation, interview and record review the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 3 of 22 residents (Resident #44, Resident #47 and Resident #95) reviewed for resident rights. 1. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #44 Representative prior to admitting to a locked unit. 2. The facility failed to find and obtain informed consent from Reasonable and Responsible party for, Resident #47, who did not have the cognitive ability to make medical decisions, who was taking medications for psychiatric diagnosis, and resided in the locked unit. 3. The facility…
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 · E2024-03-29 · tag F0728 — failed to protect against nurse-aide misconduct — patternEnsure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure 1(NA A) of 1 Nurses' Aides were not working in the facility longer than four months without being enrolled in or having completed an approved training course. The facility failed to ensure NA G was a certified nursing aide (CNA) within the required time frame. This failure place residents at risk for receiving care from an individual whose skill level was not known. Findings included: Record review of the facility staff roster provided upon entrance revealed: Nurses' Aide G was listed as a Nursing Assistant with an 04/24/2023 hire date. During an interview with HR on 03/29/2024 at 12:15 p.m., HR stated Nurses' Aide G did have a start date of employment at the facility on 04/24/2023 and she did not know if he had taken any type of CNA test for certification but did know Nurses' Aide G was listed on the staff list. During an interview with LVN C on 03/29/2024 at 1:15 pm, she stated that the nurse aide had completed his skills checklist, but she did not know why he had not taken the certification test. During an…
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 · D2024-03-29 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 24 residents (Resident #95) reviewed for advanced directives, in that: The facility failed to ensure Resident #95's Out-of-Hospital Do Not Resuscitate (OOH DNR) was dated and signed by the physician which made the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings included: Record review of Resident #95's face sheet, dated 3/27/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbance, cognitive communication deficit, lack of coordination, type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), anoxic brain damage (complete…
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 before2024-03-29 · 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 record review and interviews, the facility failed to complete an accurate assessment which reflected the resident's status for 1 of 5 residents (Resident #78) reviewed for unnecessary medications. The facility failed to ensure Resident #78's diagnosis of depression was included in the residents annual MDS assessment on 01/31/2024. This failure could result in inadequate care due to an incomplete assessment of the resident's psychological condition. The findings included: Record review of Resident #78's face sheet, dated 3/28/2024, reflected a [AGE] year-old male resident initially admitted on [DATE], with a primary diagnosis of Type 2 Diabetes (the bodies inability to regulate sugars). Record review of Resident #78's Annual MDS Assessment, dated 1/31/2024, reflected that the resident did not have depression under the section Active Diagnosis. The MDS Assessment further reflected that Resident #78 was cognitively intact. Record review of Resident #78's Order Summary Report, dated 3/28/2024, reflected 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 · D2024-03-29 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments person-centered care plan to reflect the current condition for 1 of 22 residents (Resident #44) reviewed for care plan revisions. 1. The facility failed to ensure Resident #44's care plan was comprehensive and updated to reflect Resident #44 resided on a locked unit, listed her allergies, listed her code status, and contained interventions for her dementia diagnosis. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1. Record review of Record review of Resident #44's face sheet revealed a [AGE] year-old female was admitted on [DATE] with diagnosis that included dehydration, dementia, muscle weakness, generalized anxiety disorder, seizures, insomnia, and cognitive communication…
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 before2024-03-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 resident (Resident #47) reviewed for incontinent care, in that: The facility failed to ensure CNA G properly cleaned Resident #47 vaginal area after an incontinent episode. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Record review of Resident #47's face sheet revealed a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included mood disorder due to known physiological condition with major depressive like episode, bipolar disorder severe with psychotic features (a mood disorder that features extreme shifts in mood, during which psychosis can occur. People with psychosis experience a disconnected view of reality. It can involve hallucinations 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.
- Potential for harm · D2024-03-29 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 administer a psychotropic medication to treat a specific, diagnosed condition for 1 of 5 residents (Resident #78) reviewed for unnecessary medications. Resident #78 was being administered a psychotropic medication (Paroxetine, an antidepressant used to treat depression) since 01/12/2024 without having an active and current diagnosis of depression. This failure could result in residents receiving unnecessary medications. The findings included: Record review of Resident #78's face sheet, dated 3/28/2024, reflected a [AGE] year-old male resident initially admitted on [DATE], with a primary diagnosis of Type 2 Diabetes (the bodies inability to regulate sugars). Record review of Resident #78's Annual MDS Assessment, dated 1/31/2024, reflected that the resident did not have depression, insomnia, or adjustment disorder under the section Active Diagnosis. The MDS Assessment further reflected that Resident #78 was cognitively intact. Record 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 · Dcited before2024-03-29 · 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 observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 4 medication cart (100 hall and 500 Hall medication cart) reviewed for storage of drugs. The Facility failed to provide change direction labels for 2 medications packages which had their medication orders changed. This deficient practice could place residents at risk of medication misuse and diversion. The findings were: Observation on 03/28/24 at 08:04 a.m. revealed a package in the 500-hall medication cart contained medication for Resident #39 with a label for Divalproex and instructions for 250 mg give 1 tab twice daily and 1 tablet of 125 mg to equal 375 mg. Observation on 03/28/24 at 08:16 a.m. revealed a package in the 100-hall medication cart contained medication for Resident #82 with a label for Divalproex and instructions for 125 mg, give 2 capsules to equal 250 mg every 12 hours. During an interview on 03/28/24 at 8:16 a.m., CMA J stated the medication package in the 500 cart for…
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 · D2024-03-29 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all dietary staff were confirmed to have appropriate competencies and skillsets to carry out the functions of food and nutrition service for 1 of 1 facility (Activity Director) reviewed for food preparation. The activity director was concluded on 03/27/2024 to be preparing food for resident use without having evidenced a food handlers' certificate to the facility. This failure could place all residents who consume food prepared during activities at increased risk of food-borne illness and not receiving adequate nutrition. Findings included: Observation on 3/27/2024 at 2:45 PM revealed 2 reach-in refrigerator/freezer combination units and a deep freezer which contained: 3 dozen eggs, 2 gallons of whole milk, 1 bottle of caramel drizzle dated 3/18/2024, 1 bottle of chocolate syrup dated 07/2023, 1 bottle of mustard dated 2/22/2024, 1 frozen non-alcoholic [NAME] mixer dated 10/21/2023, and 4 large gallon sized bag containers of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-29 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 safely for 1 of 1 facility reviewed for kitchen sanitation. The facility failed to discard all past dated food in the activities refrigerators, and ensure all food items contained a label in the activities freezer and kitchen Freezer #5 as observed on 03/27/2024. This failure could place all residents who consume food prepared by facility staff at increased risk of food-borne illness and not receiving adequate nutrition. The findings included: Observation on 3/27/2024 at 10:45 AM revealed reach-in freezer unit #5 to contain the following items: 1 bag of diced meat, unlabeled; 1 bag of meat tenders, unlabeled; 1 bag of meat balls, unlabeled; 3 bags of meat cutlets, unlabeled. Interview on 03/27/2024 at 11:25 AM, the DM stated she was unaware of the unlabeled food items observed within reach-in freezer unit #5 and stated it was her expectation 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 · E2024-02-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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
Based on observations, interview and record reviews, the facility failed to ensure the resident environment was as free of accident and hazards as possible for 3 of 5 halls (100 hall, 200 hall, and 300 hall) reviewed for accident and hazards, in that: 1. The facility failed to prevent a container of unsecured bleach wipes from being found on the 100 hallway. 2. The facility failed to ensure the door to the utility area was locked and the room housing hazardous material was locked on the 200 hallway. 3. The facility failed to ensure the supply room containing small objects and food items was unlocked on the 300 hallway which was a secure unit for residents with cognitive concerns. These deficient practices could result in residents coming into contact with dangerous materials which could place them at risk of injury or death. The findings were: 1. Observation on 02/08/2024 at 1:32 p.m. of the incontinent care cart on 100 hallway revealed a container of bleach wipes labeled, Danger and Keep Out of Reach of Children. During an interview with CNA A on 02/08/2024 at 1:35 p.m., CNA 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.
“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
$14,255 in federal fines across 1 penalty.
- $14,255 — penalty dated 2025-05-09
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to WELLSENTIAL HEALTH — 67 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.7 | +1.3 vs chain |
| Health inspection | 4 of 5 | 2.9 | +1.1 vs chain |
| Staffing | 3 of 5 | 1.6 | +1.4 vs chain |
| Quality measures | 4 of 5 | 4.2 | -0.2 vs chain |
The other 66 homes this chain runs (chain average 2.7★, per CMS)
Showing 40 of 66; lowest-rated first.
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| VAL VERDE COUNTY HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 04/01/2022 |
| REGENCY IHS OF PEARSALL, LLC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2022 |
| CSV RHEA MANAGEMENT HOLDCO, LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 04/01/2022 |
| DWD TX HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 04/01/2022 |
| JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 04/01/2022 |
| REG HG OPCO 1, LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 04/01/2022 |
| REG HG OPCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 04/01/2022 |
| REG OPERATOR HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 04/01/2022 |
| REGENCY INTEGRATED HEALTH SERVICES LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2022 |
| REGENCY TEXAS HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 04/01/2022 |
| BAIRD, DANIEL | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 04/13/2021 |
| CLAPP, BARBARA | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 06/01/2021 |
| CORTESE, DAREN | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 08/10/2021 |
| DIAZ, CRIS | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 05/25/2022 |
| GIBSON, PATRICIA | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 08/01/2021 |
| JURADO, JORGE | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | — | since 10/13/2023 |
| MANDELBAUM, ELLIOT | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2025 |
| OTAZO, JULIO | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 05/25/2022 |
| PALMER, ROBIN | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 11/18/2020 |
| CHAGOYA, JAVIER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2022 |
| DEKOWSKI, DONOVAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2022 |
| 169 MEDICAL DRIVE LLC | Organization | ADP OF THE SNF | — | since 04/01/2022 |
| REGENCY IHS CLINICAL CONSULTING, LLC | Organization | ADP OF THE SNF | — | since 04/01/2022 |
| REGENCY IHS MASTER TENANT LLC | Organization | ADP OF THE SNF | — | since 04/01/2022 |
| REGENCY IHS REHAB LLC | Organization | ADP OF THE SNF | — | since 04/01/2022 |
| CASAS, CARLOS | Individual | ADP OF THE SNF | — | since 01/01/2025 |
| GARZA, OSCAR | Individual | ADP OF THE SNF | — | since 04/01/2022 |
| HOUT, LUCIE | Individual | ADP OF THE SNF | — | since 01/01/2025 |
CMS files one row per role, so the 37 rows in the source record cover these 28 parties — each is shown once here with every role it holds. Nothing is omitted.
14 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.
About 86% 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.
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
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
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 455797. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-16, 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 →
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