Pflugerville Nursing And Rehabilitation Center
104 Rex Kerwin Court, Pflugerville, TX 78660 · Government - Hospital district · 120 certified beds · (512) 251-3915 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (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 | 5 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 | 5 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 2 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 | 20.7% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.4% | 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 | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.6% | 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 | 5.7% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.4% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.7% | 18.0% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.5% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.3% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.7% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 99.1% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 32.3% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 4.7% | 12.3% | 12.0% | better |
‡ 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.
57.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 21 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | 57.4%CMS range 42.0–72.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.5%CMS range 7.0–17.0 | 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 | 61.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 47.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 42.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were 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 — 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 | 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 | 0.0% | 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 | 6.6%CMS range 4.0–13.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 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 120 beds and averages 106.8 residents a day — about 89% occupied, or roughly 13 beds typically open. It runs fairly full. 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 2.89 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 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 2.47 hrs/resident/day on weekends vs 3.06 on weekdays — 19% thinner on weekends. RN hours go from 0.39 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% 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.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · D2026-07-02 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of 12 residents (Resident #1) reviewed for abuse and neglect. 1. The facility failed to prevent CMA A from mistreating Resident #1. CMA A threw a blanket on Resident #1's head and left the room without removing it from Resident #1's face who struggled to remove it herself. 2. The facility failed to ensure CMA A did not forcefully move Resident #1's jaw to administer medications while Resident #1 was not fully awake. These failures could place residents at risk for staff mistreatment. Findings include: Record review of Resident #1's care plan, dated 05/14/2026, reflected the problem: [Resident #1] is dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits with indicated interventions: all staff to converse with Resident #1 while providing care, and reflected the problem: 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 · D2026-07-02 · 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, 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 for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure CMA A and CMA H accurately documented Resident #1's medications on 06/19/2026, 06/20/2026 and 06/21/2026. This failure could place residents at risk of medication error or not receiving the intended therapeutic benefit of their medication and delayed healing. Findings include: Record review of Resident #1's care plan, dated 05/14/2026, reflected the problem: [Resident #1] is dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits with indicated interventions: all staff to converse with [Resident #1] while providing care, and reflected the problem: The [Resident #1] has impaired cognitive function related to dementia…
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 before2026-05-28 · 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 make sure that drugs are stored in locked compartments and only authorized persons have access for 1 of 8 medication carts reviewed for pharmacy services. The facility failed to ensure one nursing medication cart was locked. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings included: Observation of hall 400 on 05/26/2026 at 6:01 a.m. revealed a nursing medication cart was along the wall unattended and unlocked. The nursing medication cart contained residents' prescription drugs, over the counter medications, narcotics in a locked box, and syringes and other supplies. There were no residents, visitors, or staff in the hallway or near the nurse's cart. All the residents in the 400 hallway had their doors closed. RN A was sitting at the nurse's station on the telephone. During an interview on 05/26/2026 at 6:10 a.m., RN A stated she had been trained in medication storage. RN A stated the policy 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 · F2026-02-06 · tag F0657 — failed to keep the care plan current — widespreadDevelop 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 interviews and record reviews the facility failed to ensure a comprehensive care plan was developed within 7 days after completion of the comprehensive assessment and reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 67 of 105 (1, 2, 3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25, 26,27,28,29,30, 31, 32, 33, 34, 35, 36, 37, 38, 39,40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67 ) residents reviewed for IDT meetings/ care plans in that:The facility failed to complete a quarterly assessment for Residents 1, 2, 3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25, 26,27,28,29,30, 31, 32, 33, 34, 35, 36, 37, 38, 39,40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67 very 3 months (08/01/2025 through 12/012025).This failure could lead to residents not receiving necessary,…
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 before2025-06-25 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect are reported immediately, but not later than 24 hours if the events that cause the allegation involve abuse and do not result in serious bodily injury for 1 of 3 residents (Resident #1) reviewed for abuse and neglect, in that: The facility failed to ensure that the DON reported allegations of abuse immediately, but no later than 2 hours to the ADM when Resident #1 reported she gave me a bruise to the DON on 06/12/2025. This failure could result in continued abuse or neglect of residents, injury, and/or psychosocial harm. Findings include: Review of Resident #1 face sheet reflected a year-old female admitted on [DATE] with diagnoses of major depressive disorder (serious mental illness characterized by sadness, loss of interest in activities and other symptoms that interfere with daily life), anxiety disorder (persistent worry and fear that can interfere with daily life), and impulse 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 · Ecited before2025-04-03 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure residents were given the appropriate services to maintain activities of daily living (ADLs) for three of seven residents (Resident #67, Resident #18, and Resident #2) reviewed for ADL abilities. Resident #67 had dirty, jagged fingernails and flaky, dry skin on legs. Resident #18 had long, jagged fingernails. Resident #2 had long, jagged fingernails, chipped nail polish and unbrushed teeth. This deficient practice could place residents who required assistance at risk of or not receiving care and services to meet their needs and avoid ADL decline. Findings included: Resident #67 Review of Resident #67's face sheet, dated 04/02/2025, reflected an [AGE] year-old female admitted to the facility on . Her diagnosis was Unspecified Dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities. Record review of Resident #67's quarterly MDS dated [DATE] reflected Resident #67…
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 before2025-04-03 · 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 food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary [NAME] C, Dietary [NAME] D and Dietary Aide E used proper hand hygiene during food preparation. 2. The facility failed to ensure Dietary Aide E wear a hair net and Dietary Aide F wear a beard guard when standing over the oven and the food prep table. These failures could place residents who ate food from the kitchen at risk for foodborne illness. Findings included: 1. Observation on 03/31/2025 at 9: 20 AM Dietary [NAME] C was wearing gloves in the kitchen. She was standing by the stove preparing lunch. Dietary [NAME] touched the right side of her shirt when she moved her right hand from her right side to the handle of the utility cart. She placed her right hand on the shredded cabbage located in a large plastic bag on the utility cart. Dietary [NAME] C touched the outside of the bag with her right hand prior to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-03 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
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 dispose of garbage and refuse properly for one of one kitchen 1. The facility failed to keep overflowing garbage away from an area where food was being prepared for resident meals. 2. The facility failed to keep garbage away from an area where clean cook ware was stored. These failures could place residents at risk for exposure of germs and diseases carried by vermin and rodents. Findings Included: Observation on 04/01/2025 at 2:30 PM revealed there was a garbage barrel with the lid off on half of the barrel. There was overflowing garbage with cans and boxes with food residue inside and outside of the cans, containers and, boxes located in the garbage barrel. The garbage barrel was located approximately three feet from the stove-oven, and less than two feet away from clean pans in the food prep area. Observation on 04/02/20255 at 6:05 AM revealed there was a garbage barrel with the lid not completely covering the top of the barrel. There were boxes, food, and a large can inside the garbage barrel. There was 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 · E2025-04-03 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interviews, the facility failed to maintain an effective pest control program so that the facility was free of pests for one of one kitchen reviewed for pests. Cockroaches were seen in the kitchen near the garbage can located beside clean pots and pans and one located in the dining room near the large wall of cabinets. This failure could place residents at risk of infection, discomfort, and diminished quality of life. Findings included: Observation on 04/02/2025 at 6:05 AM revealed a cock roach was beside a garbage can located by shelves full of pots and pans. Observation on 04/02/2025 at 6:08 AM, a cock roach was moving from underneath the garbage can located by the shelves of pots and pans into the dishwasher area. Observation on 04/02/2025 at 7:10 AM a cock roach was near the large cabinets against the wall in the dining room. Interview on 04/02/2025 at 6:35 AM The Dietary Manager stated anytime roaches, or any type of pest was observed in the kitchen she would report it to the Maintenance Supervisor. She stated the pest control company…
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 · D2025-04-03 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed, to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident , encouraging both independence and interaction in the community for one of five residents (Resident #15) reviewed for activities. The facility failed to provide Resident #15 in room activities during the months ofFebruary and March of 2025. This failure could place residents at risk for boredom, depression, and diminished quality of life. Findings included: Review of Resident #15's Face sheet , dated 04/02/2025, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnosis: vascular dementia, unspecified severity, with mood disturbance ( a type of dementia caused by conditions that damage blood vessels in the brain,…
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 18 citations
- Potential for harm · Dcited before2025-04-03 · 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 medications and biological's were stored in locked compartments for one of seven (Hall 300 medication cart) medication carts reviewed for medication storage. The facility failed to ensure Hall 300 medication cart was locked and medications were secure and not accessible to other staff, resident, or visitors. This failure could place residents at risk of having unauthorized access to medications, biological's, and needles. Findings included: Observation on 03/31/2025 at 3:30 PM revealed a unlocked medication cart on Hall 300; located near the entrance of the hallway, closest to the nurse's station. The back of the cart was against the wall with the drawers facing the hallway. The state surveyor observed the medication cart with the locking mechanism protruding outward. The state surveyor opened the drawers and captured photos. During an interview on 3/31/2025 at 3:40 PM, the RN said she thought she had locked the medication cart on Hall 300 before she walked away. She said she could not believe the 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 · D2025-04-03 · tag F0802 — failed to prepare enough nourishing food — isolatedProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
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 employ staff with the appropriate competencies and skill sets to conduct the functions of the food and nutrition services for one of three kitchen staff (Dietary Aide E) reviewed for qualified dietary staff. Dietary Aide E had not received onboarding training with the appropriate competencies and skills to conduct the functions of the food and nutrition services department and his food handler certificate was expired. This failure placed residents at risk of not having their nutritional needs met and placed them at risk of food borne illness. Findings included: Interview and observation on 04/02/2025 at 5:35 AM Dietary Aide E introduced himself as the [NAME] for the day (he did not mention he was in training to be a cook). He stated he did not know when the Dietary Manager was coming in for the day. Dietary Aide E stated the Dietary Manager usually came to work between 7:30 AM and 8:00 AM. He was observed placing pots on the stove. Observation on 04/02/2025 at 6:12 AM Dietary Aide E in training placed…
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 · D2025-04-03 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 prepare food by methods that conserve nutritive value for 1 of 1 kitchen observed. The facility failed to provide a recipe for pureeing sausage which resulted in Dietary Aide E adding an unmeasured amount of water to the puree. This failure could place residents at risk of decreased food intake, hungry, unwanted weight loss, and diminished quality of life. Findings included: Observation on 04/02/2025 at 6:12 AM Dietary Aide E placed 28 sausage patties into the puree blender. He had a pitcher of water and began pouring water without measuring. Interview on 04/02/2025 at 6:14 AM Dietary Aide E stated he had never puree food before and he was guessing how much water needed to be in the container with the sausage before he pureed the sausage. He did not know if he was to view the recipe prior to pureeing the sausage. He stated he had cooked by himself before, and he usually did puree at 6:25 AM or 6:30 AM without anyone assisting him. The Dietary Manager entered the kitchen, he stated Dietary Aide E had never…
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 before2025-04-03 · 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 2 of 4 residents (Resident #35 and, Resident #68) reviewed for infection control: 1. The facility failed to ensure MA B sanitized the nasal spray before it was used in Resident #68's nostril and before storing it in the med cart after her use. 2. The facility failed to ensure CNA A was not using soiled gloves while handling clean items during peri care on Resident #35. These failures could place residents at-risk for infection due to improper care practices. Findings included: Review of Resident #35's Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #35 had diagnoses of Alzheimer's disease, Anxiety disorder, Major depressive disorder, Age-related physical debility, Lack of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-01 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that all allegations involving abuse, neglect, or serious bodily injuries were reported immediately but not later than 24 hours after the allegation was made for one (Resident #1) of five residents reviewed for abuse and neglect. The facility failed to report to the State Agency an incident on the facility's van where the Van Driver failed to ensure Resident #1 was properly strapped in the facility's van on 09/23/2024. This deficient practice could place residents at risk of abuse and neglect. Findings included: Review of Resident #1's face sheet dated 10/01/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmission date of 08/31/2024 with diagnoses that included end stage renal disease, type 2 diabetes mellitus, and encephalopathy (describe a disease that affects the brain structure or function. It causes altered mental status and confusion) unspecified. Review of Resident #1's care plan revised 02/28/2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-01 · 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 observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 (Resident #2) of 2 residents reviewed for blood glucose monitoring. RN A failed to perform hand hygiene and wear gloves while checking Resident #2's blood glucose. This failure place residents at risk of infections. Findings included: Review of Resident #2's face sheet dated 10/01/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmission date of 04/02/2024 with diagnoses that included end stage renal disease, type 2 diabetes mellitus, peripheral vascular disease, and dependence on renal dialysis. Review of Resident #2's care plan initiated 02/13//2024 reflected Resident #2 had an ADL self-care performance deficit related to right below the knee amputation, independent with all ADL's and driving. It was also reflected Resident #1 was at risk for fluid volume overload 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 · D2024-09-17 · 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 interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. The facility failed to check Resident #1's glucose level or A1C for five months after he was admitted to the facility with a diagnosis of type II diabetes and was recently discontinued from Metformin and Trulicity (medications utilized to manage high blood glucose levels with individuals with type II diabetes) at the hospital. These failures could place residents at risk of not receiving necessary medical care, harm, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 08/25/24 with diagnoses including type II diabetes, stroke, hypertension (high blood pressure), and vascular dementia (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 · Ecited before2024-02-16 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all resident who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of 8 (Resident #210, Resident #213, and Resident #10) residents reviewed for activities of daily living. 1. The facility failed to ensure Resident #210 and Resident #213 received nail care. 2. The facility failed to ensure Resident #10 received help with eating. These failures placed residents at risk of poor hand hygiene, skin tears, infection, poor nutrition, and weight loss. Findings included: 1. A record review of Resident #210's undated face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses of hypertension (high blood pressure), dysphagia (difficulty swallowing), atherosclerotic heart disease of native coronary artery (narrowing of arteries), need for assistance with personal care, type 2 diabetes (uncontrolled blood sugar), end stage renal disease…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-16 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all residents were free from unnecessary drugs for 1 (Residents #63) of 3 residents reviewed for unnecessary drugs. -The facility failed to implement or provide reasoning for not implementing the recommendation by the licensed pharmacist to update the diagnosis for Seroquel XR for resident #63. -The facility failed to develop policies and procedures to address the timeframes of the medication regimen review. This failure could place resident as risk of not having their pharmacy consultations reviewed or recommendations implemented. The findings included: Review of Resident #63's face sheet printed 02/16/24, reflected a [AGE] year-old female most recently admitted to the facility on [DATE]. Her diagnoses included Guillain-Barre syndrome (a disorder of the immune system that causes weakness and tingling in arms and legs), other chronic pain, major depressive disorder (a mood disorder with persistent feeling of sadness and loss of interest),…
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 · E2024-02-16 · 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, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10.71 % based on 3 errors out of 28 opportunities, which involved 2 of 4 residents (Resident #38 and Resident #44) reviewed for medication administration. 1. The facility failed to ensure MA H administered medication as ordered to Resident #38 by administering Ferrous Sulfate 325mg instead of Ferrous Fumarate 324mg. 2. The facility failed to ensure MA H administered medication as ordered to Resident #44 by administering Calcium 600mg instead of Calcium 600mg with Vitamin D3 5mcg and Aspirin 81mg chewable tablet instead of Aspirin 81mg Delayed Release tablet. These failures could affect residents and put them at risk for not receiving the intended therapeutic benefit of their medication and or adverse outcomes. The findings included: Resident #38 Review of Resident #38's face sheet printed on 02/15/24 reflected an [AGE]…
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 before2024-02-16 · 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 labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication storage rooms reviewed for medication storage. The facility failed to date two multi-use vials of Tuberculin, Purified Protein Derivative, Diluted Aplisol (a solution used to administer Tuberculin skin tests) when opened. This failure could place residents and staff at risk of not receiving the intended effect or contaminated solution. The findings included: An observation on 2/14/24 at 3:14 PM revealed two opened and accessed multi-dose-vials of Diluted Aplisol in the refrigerator in the medication storage room. Neither vial was dated or initialed when opened. During an interview on 02/14/24 at 3:17 PM with RN C, she stated all multi-use vials and bottles had to be dated when opened. She stated the nurse opening the vial was responsible for dating 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 · Ecited before2024-02-16 · 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 for 1 of 1 kitchen reviewed for sanitation. The facility failed to ensure all items were properly covered, dated and discarded when expired. The facility failed to ensure CK L washed her hands as required and sanitized dishes properly. These failures placed resident risk of foodborne illness. Findings included: -An observation of the kitchen on 2/13/2024 at 7:02 a.m. revealed the reach-in refrigerator contained the following: -An opened container of tartar sauce with an opened date of 9/27/2023. -An opened container of mayonnaise with a received date of 2/08/2024. -A plastic meal tray with two cups of shredded cheese which were not completely covered from air and two cups of shredded cheese completely uncovered. There were also three 4-oz cups of bacon uncovered. During an observation and interview on 2/13/2024 at 7:14 a.m., the Dietary Manager stated she had drilled them over and over that items should…
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 before2024-02-16 · 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 observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 staff (CNA I) viewed for infection control. The facility failed to ensure CNA I performed hand hygiene when changing gloves while providing catheter care. This failure could place residents at risk for infection or a decline in health. The findings included: Review of Resident #85's face sheet printed 02/16/24 reflected an [AGE] year-old male initially admitted to the facility on [DATE] and re admitted on [DATE]. His diagnoses included unspecified dementia, anemia (lack of red blood cells in the blood), paroxysmal atrial fibrillation (irregular heartbeat), chronic kidney disease, and benign prostatic hyperplasia with lower urinary tract symptoms (urine flow is impaired due to an enlarged prostate). 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 · D2024-02-16 · 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 interviews and record reviews, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Level 1 Screening for 1 of 4 residents reviewed for PASRR (Resident #94). The facility failed to ensure Resident #94 had an accurate PASRR Level 1 Screening indicating a diagnosis of mental illness on 02/26/23. This failure could place residents at risk of not receiving needed individualized care, and specialized services to meet their needs.\ Findings included: Review of Resident #94's face sheet printed on 02/15/24 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included bipolar disorder (a mental illness that causes extreme mood swings), type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), hypertension (high blood pressure), and Bell's Palsy (a condition that causes temporary weakness or paralysis of the muscles in the face). Review of Resident #94'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 · D2024-02-16 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all residents were provided foot care and treatment, in accordance with professional standards of practice, for 2 of 8 (Resident #72 and Resident #82) residents reviewed for podiatry care. The facility failed to ensure Resident #72 and Resident #82 received podiatry care. This failure placed residents at risk of untreated podiatry issues, long nails, skin tears, and infection. Findings included: A record review of Resident #72 face sheet dated 2/14/2024 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia, age-related physical debility (weakness), phantom limb syndrome (the ability to feel sensations and even pain in a limb or limbs that no longer exist), and gastro-esophageal reflux disease (acid reflux). A record review of Resident #72's quarterly MDS assessment dated [DATE] reflected a BIMS score of 12, which indicated minimally impaired cognition. A record review of Resident #72's care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible or prevent accidents for 2 of 2 residents (Resident #12 and #77) reviewed for accidents and hazards in that: The facility failed to ensure Resident #12 and Resident #77 had fall mats in place in accordance with physician's orders and care plans. This failure could place residents at risk for injury. The findings included: Record review of Resident #12's face sheet dated 02/15/24 revealed an [AGE] year old female admitted [DATE] with a diagnoses of unspecified dementia-moderate-with anxiety (group of symptoms that affects memory, thinking, and interferes with daily life), atherosclerotic heart disease of native coronary artery without angina pectoris (narrowing or blocked arteries), mixed hyperlipidemia (abnormally high levels of any or all lipids or lipoprotein in the blood), essential (primary) hypertension, repeated falls, age related physical…
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 · D2024-02-16 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 1 resident (Resident #212 ) reviewed for nursing services. The facility failed to ensure the DON was competent in policy and procedure in PICC line removal for Resident #212. These failures could result in residents receiving inadequate nursing care and decreased quality of life. Findings included: Record review of Resident #212's face sheet dated 02/15/24 revealed a [AGE] year-old female admitted [DATE] with a diagnoses of acute and subacute infective endocarditis (an infection of the endocardial surfaces of the heart, which includes one or more heart valves), essential (primary) hypertension (high blood pressure), chronic viral Hepatitis C (viral infection that causes inflammation of the liver), opioid abuse uncomplicated, anxiety…
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 · D2024-02-16 · 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 observation, interview and record review, the facility failed to ensure all residents who had not used psychotropic drugs were not given those drugs and that all residents on psychotropic drugs received a gradual dose reduction for 1 of 8 (Resident #31) residents reviewed for psychotropic drugs. The facility failed to ensure Resident #31 had a preexisting mental illness for which psychotropic drugs (Cymbalta and Zyprexia) would be warranted. The facility failed to ensure Resident #31 received a gradual dose reduction for Cymbalta (antidepressant) and Zyprexia (antipsychotic). These failures placed residents at risk of unnecessary psychotropic drug use. Finings included: A record review of Resident #31's face sheet dated 2/15/2024 reflected a [AGE] year-old female readmitted on [DATE] with diagnoses of neurocognitive disorder with Lewy bodies (type of dementia), type 2 diabetes (uncontrolled blood sugar), hypertension (high blood pressure), major depressive disorder (depression), vascular dementia with…
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.
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 | 5 of 5 | 2.7 | +2.3 vs chain |
| Health inspection | 4 of 5 | 2.9 | +1.1 vs chain |
| Staffing | 2 of 5 | 1.6 | +0.4 vs chain |
| Quality measures | 5 of 5 | 4.2 | +0.8 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 | Since |
|---|---|---|---|
| REGENCY IHS OF PFLUGERVILLE LLC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/28/2015 |
| CSV RHEA MANAGEMENT HOLDCO, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 02/28/2015 |
| DWD TX HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 02/28/2015 |
| JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INC | Organization | INDIRECT OWNERSHIP INTEREST | since 02/28/2015 |
| REG BRIDGE OPCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 02/28/2015 |
| REG HG OPCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 02/28/2015 |
| REG OPERATOR HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 02/28/2015 |
| REGENCY INTEGRATED HEALTH SERVICES LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/28/2015 |
| REGENCY TEXAS HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 02/28/2015 |
| ALEXANDER, ALMA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | since 05/27/2020 |
| BAIRD, DANIEL | Individual | MANAGING CONTROL - GOVERNING BODY | since 04/13/2021 |
| CARVAJAL, ANTONIO | Individual | MANAGING CONTROL - GOVERNING BODY | since 05/16/2024 |
| CLAPP, BARBARA | Individual | MANAGING CONTROL - GOVERNING BODY | since 06/01/2021 |
| CORTESE, DAREN | Individual | MANAGING CONTROL - GOVERNING BODY | since 08/10/2021 |
| FRELS, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY | since 11/04/2014 |
| GIBSON, PATRICIA | Individual | MANAGING CONTROL - GOVERNING BODY | since 08/01/2021 |
| GONZALES, VERONICA | Individual | MANAGING CONTROL - GOVERNING BODY | since 05/16/2024 |
| KAUFMAN, NICOLE | Individual | MANAGING CONTROL - GOVERNING BODY | since 08/10/2021 |
| MANDELBAUM, ELLIOT | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2025 |
| PAPACEK, CHARLES | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | since 10/01/1997 |
| SHEPPARD, ANNA | Individual | MANAGING CONTROL - GOVERNING BODY | since 05/01/2019 |
| SHEPPARD, CYNTHIA | Individual | MANAGING CONTROL - GOVERNING BODY | since 06/25/2013 |
| DEWITT MEDICAL DISTRICT | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/28/2015 |
| CHAVIES, AKIL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/19/2019 |
| DEKOWSKI, DONOVAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/28/2015 |
| 104 REX KERWIN COURT LLC | Organization | ADP OF THE SNF | since 02/28/2015 |
| REGENCY IHS CLINICAL CONSULTING, LLC | Organization | ADP OF THE SNF | since 02/28/2015 |
| REGENCY IHS REHAB LLC | Organization | ADP OF THE SNF | since 02/28/2015 |
| BURK, ALLISON | Individual | ADP OF THE SNF | since 01/01/2025 |
| FELDER, LATANYA | Individual | ADP OF THE SNF | since 01/01/2025 |
| GUTIERREZ, MICHAEL | Individual | ADP OF THE SNF | since 01/01/2025 |
CMS files one row per role, so the 40 rows in the source record cover these 31 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
13 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 82% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 676245. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.