Plainview Healthcare Center
2510 W 24th St, Plainview, TX 79072 · Government - Hospital district · 93 certified beds · (806) 296-5584 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $19,190 in federal fines (most recent 2024-09-20)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 8.9% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.5% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.1% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.3% | 0.8% | 2.0% | worse 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 | 1.2% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.7% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.1% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.8% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.3% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.9% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.0% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.9% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.8% | 25.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.6% | 12.3% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.11 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.28 | 2.06 | 1.80 | worse |
* 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.
55.7% 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 50 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 38.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 34 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 0.29 therapist hours per resident per day in 2026Q1 — more than 46% 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 | 55.7%CMS range 40.9–65.7 | 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 | 8.7%CMS range 5.3–12.8 | 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 | 38.2% | 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 | 44.1% | 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 | 26.5% | 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 | 76.0% | 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 | 92.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.0% | 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 | 2.0% | 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 | 6.9%CMS range 3.5–12.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.00 | 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 93 beds and averages 51.8 residents a day — about 56% occupied, or roughly 41 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 2.71 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.17 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.45 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 2.52 hrs/resident/day on weekends vs 2.79 on weekdays — 10% thinner on weekends. RN hours go from 0.18 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · Kcited before2024-09-20 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, it was determined the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for 2 of 5 residents (Residents #1 and #2) reviewed for Quality of Care. The facility failed to ensure Resident #1's surgical wound was assessed, and wound care orders were received from the hospital upon admission to the facility. Resident #1 had a post-surgery check up on 9/3/24, 18 days after admission and the bulky wound dressing from the surgery was still covering the wound and was dried to his leg but the incision was not infected. The facility failed to ensure Resident #2's surgical wound was assessed, and wound care orders were received from the hospital upon admission to the facility. Resident #2 had a post-surgery check up on 9/3/24, 13 days after admission and the bulky wound dressing from the surgery was still covering the wound and was soaking wet. No…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-07-01 · 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 the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure the freezer, refrigerator, and pantry items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illnesses. Findings included: Observation of the prep area in the kitchen on 06/29/26 at 9:25 AM revealed the following:1. (3) clear bins containing individual cereal bowls were not labeled or dated. Observation of the walk-in refrigerator on 06/29/26 at 9:27 AM revealed the following:1. (1) box of vegetables, no label or date. 2. (1) bag that contained half of a cut lemon in a foam bowl, no label or date.3. (4) bags of fresh grapes, open to air, and 1 bag contained moldy grapes.4. (1) tray of fruit cups, covered, no label, and the date was unreadable.5. (1) box of cupcakes, not sealed, no label or date. 6. (1) box containing tortillas, no label or date. Observation of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-07-01 · 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 12 residents (Residents #2 and #3), and 1 of 2 staff members observed for infection control. LVN C failed to ensure infection control with wrist blood pressure cuff and did not clean it between use of residents. The facility failed to ensure Resident #3's catheter bag was not dragging on the floor. C.N.A. E failed to ensure infection control by not changing gloves prior to starting pericare for Resident #3. C.N.A. F failed to ensure infection control by not changing glovers prior to catheter care for Resident #3. C.N.A. G failed to ensure infection control by not changing gloves prior to starting pericare for Resident #2. This deficient practice could put residents at risk for increased infections. Findings…
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 before2026-07-01 · 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, that meet professional standards of quality and that included measurable objectives and time frames for 1 of 11 (Residents #3) Residents reviewed for care plans.A. The facility failed to ensure Resident #3's daily use of compression socks had been care planned. There was no documentation in the care plan of measurable objectives, interventions, or timeframes for how staff would meet this need.This failure to accurately develop and implement a care plan could result in staff not being aware of critical treatment-related risks and monitoring needs, placing residents at risk for delayed treatment and failure to provide necessary care and services. Findings include:Record review of Resident #3 's face sheet printed 06/29/2026 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of embolism ( a traveling mass of undissolved matter…
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 before2026-07-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 11 residents (Resident #3) reviewed for physician orders for treatments. The facility failed to follow physician orders and apply Compression socks as ordered for Resident # 3. The failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings include:Record review of Resident #3 's face sheet printed 06/29/2026 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of embolism ( a traveling mass of undissolved matter such as a blood clot ) deep vein thrombosis of lower extremities bilateral (blood clot in deep vein of legs), fluid overload (when body retains too much fluids), acute on chronic diastolic congestive heart failure (decompensation 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 · Fcited before2026-01-07 · tag F0837 — widespreadEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
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 the governing body of the facility had appointed an administrator, who was licensed by the state, was responsible for the management of the facility, and was accountable the to the governing body for 1 of 1 facility reviewed for administration. The facility had not had an administrator from 07/16/2025 to 01/07/2026 This deficient practice could place residents at risk of decreased quality of life and quality of care due to lack of staff oversight and monitoring of care.The findings included: Record review of the former Administrator's employee record titled Profiles dated 11/20/2025 revealed he was hired on 02/01/2018 with a termination date of 07/16/2025. During an interview on 1/07/2026 at 05:56 AM the AIT reported she (AIT) had completed her administrator training and tested but she did not pass the test the first time. She (AIT) was planning on retesting. The AIT reported that the facility was actively looking for an interim administrator and has had several applications. The facility has one current applicant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-11-20 · tag F0837 — widespreadEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
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 the governing body of the facility had appointed an administrator, who is licensed by the state, to be responsible for the management of the facility and report to the governing body. The facility had not had an administrator since 07/16/2025. This deficient practice could place residents at risk of decreased quality of life and quality of care due to lack of staff oversight and monitoring of care for all 50 residents at the facility. The findings included: Record review of the former Administrator's employee record titled Profiles dated 11/20/2025 revealed he was hired on 02/01/2018 with a termination date of 07/16/2025. During an interview on 11/20/25 at 6:48 AM, an entrance conference was conducted with the AIT who stated she took the test and failed and the facility, at this time, did not have a licensed ADM. She stated the former ADM had been terminated on 07/16/25. The AIT stated that corporate wanted her to take the position of ADM as soon as she passed the ADM exam. During an interview on 11/20/25 at 5:31…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-09-04 · tag F0837 — widespreadEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
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 the governing body of the facility had appointed an administrator, who is licensed by the state, to be responsible for the management of the facility and report to the governing body. The facility had not had an administrator since 07/16/2025. This deficient practice could place residents at risk of decreased quality of life and quality of care due to a lack of staff oversight and monitoring of care. The findings included: During an interview on 09/04/2025 at 9:32 AM, an entrance conference was conducted with the BOM who stated she was the AIT and acting as ADM for the facility. She stated that the former ADM had been terminated. During an interview on 09/04/2025 at 2:04 PM, the DON stated that the facility did not have a full-time administrator. She stated that she was not exactly sure when the last administrator was terminated, but she thought around the 20th of July. The DON stated the AIT took the administrator role, but she was not licensed and still in training. During a follow-up interview on 09/04/2025 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-05-02 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchens when they failed to: A. Ensure kitchen staff used proper hand washing and sanitation procedures when handling food. This failure could cause decreased meal satisfaction and decreased meal consumption due to using unsanitary practices in the facility's only kitchen and could affect all residents in the facility that receive meals from the facility kitchen. Findings included: Observation of the kitchen food prep activities on 4/30/25 from 11:15 a.m. to 12:35 p.m. revealed the following: In an observation and interview on 4/30/25 at 11:40 a.m., [NAME] I was observed in the kitchen with gloved hands, chopping meat for lunch using a spoon to chop the meat. [NAME] I pushed meat off the bowl of the spoon with her gloved hands. [NAME] I did not wash her hands. [NAME] I took off her gloves and applied new gloves from her pocket. [NAME] I began touching the meat with her gloved hand, picked up the meat and put the chopped meat in the metal…
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 · E2025-05-02 · 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 observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 3 of 3 medication carts (NE Hall, NW Hall, and South side Hall) and 1 of 12 residents (Resident #15) reviewed for medication storage. -Medication cart for NW Hall revealed Fluticasone Propionate nasal spray 50mcg with no open date on the bottle or resident identifying information. -Breo Ellipta had a date of 06/11/2025, with no resident identifying information. -Medication cart for NE Hall had a pill in a medication cup in the top draw of the medication cart. -Medication cart for NE hall had 1 unidentified pill loose in the bottom of the medication cart drawers. -Medication cart for NE hall had 1 loose Protonix pill in the bottom of the medication cart drawers. -Medication cart for NE hall had Fluticasone Propionate nasal spray 50mcg, for Resident # 15, bottle did…
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 before2025-05-02 · 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
Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 12 residents (Resident #15, #24, #26, #27, #31, and Resident #36) reviewed for infection control. The facility failed to ensure that facility staff performed hand hygiene appropriately during medication preparation, medication administration and incontinent care. This failure could place the residents at an increased risk for potentially exposing them to viral infections, secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor hygiene. Findings included: During an observation on 04/30/25 at 11:00 AM Resident #27 was being assisted to the restroom by CNA F who did not don any PPE. Resident #27 was on EBP due to having a wound. During an interview on 04/30/25 at 11:08 AM CNA F, stated he didn't know if Resident # 27 was on EBP…
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 20 citations
- Potential for harm · D2025-05-02 · 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 observations, interviews and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 12 residents (Resident #43) reviewed for accuracy of MDS assessments. -The facility did not correctly identify oxygen therapy for Resident #43 on her MDS assessment. This failure to ensure accurate assessments could affect all the residents by placing them at risk for inaccurate and incomplete MDS assessment, which could result in the residents not receiving correct care and services. Finding included: Record review of Resident #43's face sheet, dated 05/02/2025, revealed Resident #43 was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus without complications (a condition where blood sugar levels are persistently high due to either the body's inability to use insulin effectively (insulin resistance) or the pancreas doesn't produce enough insulin, or both), pulmonary hypertension (a condition…
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 before2025-05-02 · 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 observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest t practicable physical, mental, and psychosocial well-being for 1 (Resident #37) of 16 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan that accurately addressed Resident #37's oxygen therapy. This failure could place residents at risk of not receiving desired and necessary care and treatment. Findings included: Record review of Resident #37's admission record dated 05/02/2025 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included unspecified diastolic…
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 · D2025-05-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #43) of 12 residents reviewed for respiratory care. The facility failed to administer oxygen at the correct dose for Resident #43. This failure could affect all residents on oxygen therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition. Findings included: Record review of Resident #43's face sheet, dated 05/02/2025, revealed Resident #43 was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus without complications (a condition where blood sugar levels are persistently high due to either the body's inability to use insulin effectively (insulin resistance) or the pancreas doesn't produce enough insulin, 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 · D2024-09-20 · 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 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 person-centered care of the resident that meet professional standards of quality care for one of 5 residents (Resident #1) reviewed for baseline care plans. The facility failed to develop a baseline care plan for Resident #1 that included assessment and dressing changes for a surgical wound. This failure could place residents at risk of receiving care that is substandard, unable to meet their needs, or inadequate to prevent complications such as a serious wound infection, wound deterioration, sepsis, or death. Findings include: Record review of Resident #1's clinical record revealed he admitted to the facility on [DATE], was [AGE] years of age with the following diagnoses: orthopedic aftercare of fracture of right femur (broken thigh bone), history of falling, muscle weakness, unsteadiness on feet, malignant neoplasm of prostate (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 · Dcited before2024-09-20 · 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 care plan for each resident 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 and describes the services that are to be furnished to obtain or maintain the resident's highest practicable physical, metal, and psychosocial well-being for 1 of 5 residents (Resident #2) whose comprehensive care plans were reviewed. The facility failed to develop a comprehensive care plan for Resident #2 that included dressing changes, assessing the wound for any changes and documenting in the clinical record what was found. This failure could place residents at risk of receiving care that is substandard, unable to meet their needs, or inadequate to prevent complications such as a serious wound infection, wound deterioration, sepsis, or death. Findings include: Record review of Resident #2's clinical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-22 · 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 record review and interview 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 eneds of each resident for 1 (Resident #1) of 5 residents reviewed for pharmaceutical services. The facility failed to transcribe Resident #1's order for Amitriptyline (an antidepressant medication) accurately. The dose was entered into the EHR as 100 mg per day rather than the ordered 25 mg per day. This failure could place residents at risk of receiving incorrect doses of medication resulting in overmedication. Findings Included: Record review of Resident #1's admission record dated 05/08/24 revealed a [AGE] year-old male admitted for a short term to the facility on [DATE] with diagnoses that included, but were not limited to, aftercare following joint replacement surgery, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), fracture 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 · D2024-05-22 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were free from significant medication errors for 1 (Resident #1) of 5 residents reviewed for medication errors. The facility failed to follow physician's orders in that Resident #1 was given 100 mg of Amitriptyline (an antidepressant medication) rather than the 25 mg the physician ordered. This failure could place residents at risk for oversedation such as dizziness, drowsiness and fatigue. Findings Included: Record review of Resident #1's admission record dated 05/08/24 revealed a [AGE] year-old male admitted for a short term to the facility on [DATE] with diagnoses that included, but were not limited to, aftercare following joint replacement surgery, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), fracture of base of neck of right femur (break in the neck of the big bone of the right leg near where the ball goes into the hip socket), volume depletion (abnormally low…
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 before2024-05-22 · 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
Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 1 (Resident #2) of 5 Residents in that: - The facility failed to ensure CNA performed hand hygiene during foley catheter care for Resident #2. -The facility failed to ensure CNA and HA donned PPE before entering Resident #2's room who was on EBP's. (Enhanced Barrier Precautions). -The facility failed to provide staff with adequate PPE. These failures had the potential to affect residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: During an observation on 05/08/2024 at 10:03am revealed foley catheter care for Resident #2. Care was provided by CNA and HA. CNA and HA performed HH at the beginning of care. CNA started to clean Resident #2's penis, 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 · F2024-03-21 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for one of one facility reviewed for nursing services The facility did not have an RN in the facility on 01/27/2024, 01/28/2024, 02/10/2024, 02/11/2024, 03/16/2024, and 03/17/2024. This failure placed residents at risk of not having supervisory coverage for RN specific nursing activities. Findings include: Record review of the facility's last 90 days of time sheets for RN coverage revealed that there was no RN coverage on 01/27/2024, 01/28/2024, 02/10/2024, 02/11/2024, 03/16/2024, and 03/17/2024. Interview on 03/20/24 at 2:27 PM with DON stated that she did not have that many days with no coverage. DON stated that agency did not cover that many days either. Interview on 03/20/24 at 2:32 pm with Regional DON said after she reviewed the last 90 days of time sheets for RN coverage, There was no coverage on 01/27/24, 01/28/24, 02/10/24, 02/11/24, there was no mention by Regional DON if there was RN coverage on 03/16/24, and 03/17/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-03-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
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 food service safety. The facility failed to ensure stored food was properly labelled and dated. The facility failed to ensure dented cans were placed in the specified area to be returned. The facility failed to discard expired food. The facility failed to discard leftover food by use by date on the label. The facility failed to store food at least 6 inches off the floor. These failures could place residents at risk of food borne illness. Findings included: An observation on 03/19/24 at 09:21 AM of the refrigerator revealed the following: 8 single serve apple juice cups covered with original packaging foil lids sitting on a tray with an illegible label stuck to the tray. The label appeared to have become wet and the open and use by dates were black smudges. 5 single serve cartons of strawberry and chocolate shakes were in a box with no label or date. Bologna slices in 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 · E2024-03-21 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 attempt to use appropriate alternatives prior to installing a side or bed rail and failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation and failed to ensure maintenance of bedrails for 4 (Resident #6, Resident #17, Resident #33, and Resident #53) of 20 residents reviewed for bedrails. Residents #6 and #33 had bedrails that were loose. Resident #17 had no consent for bedrails in his EHR or his paper chart. Residents #33 and #53 had bedrails the day they were admitted to the facility. These failures could place residents at risk of injury and/or entrapment. Findings Included: 1. Record review of Resident #6's admission record dated 03/19/24 revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, metabolic encephalopathy (problems in the brain from chemicals 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 · D2024-03-21 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (Resident #26 and Resident #48) of 20 residents reviewed for privacy. Resident #26's catheter bag was left without a cover in full view of anyone who entered resident's room. Resident #48's catheter bag was left without a cover in full view of other residents during mealtimes. This failure could place residents at risk of a lack of dignified existence, lowered self-esteem, or a decreased quality of life. Findings include: Resident #26 Record review of Resident #26's clinical record revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include hemiplegia (complete paralysis on one side) and hemiparesis (weakness on one side) following a cerebral infarction (stroke), and other neuromuscular dysfunction of bladder. 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 · D2024-03-21 · 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 provide residents with the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 2 (Resident #17 and Resident #4) of 20 residents reviewed for advance directives. Resident #17 had a DNR undated by the physician. Resident #4 had a DNR lacking the physician's printed name. These failures could place residents at risk of having their end of life wishes dishonored and having CPR performed against their wishes. Findings Included: 1. Record review of Resident #17's admission record dated [DATE] revealed an [AGE] year-old resident admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart failure, major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), age related cognitive decline,…
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 · D2024-03-21 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete a significant change in status assessment within 14 days after the facility determined or should have determined that a resident has a significant change in the resident physical or mental condition for 1 (Resident #14) of 20 residents reviewed for comprehensive resident assessments. The facility failed to complete a significant change of condition assessment when Resident #14 was discharged from hospice. This failure placed residents at risk for not receiving an accurate assessment and could result in lack of care. Findings include: Record review of Resident #14's clinical records face sheet printed 3-19-2024 revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest 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 · D2024-03-21 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 reviews the facility failed to perform preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 3 (Resident #17, Resident #37, and Resident #44) of 20 residents reviewed for preadmission screenings. 1. Resident #17 had a PASRR performed 36 days after he was admitted to the facility. 2. Resident #37 had a PASRR performed 12 days after he was admitted to the facility. 3. Resident #44 had a PASRR with no assessment date in her EHR. These failures could place residents at risk of receiving inadequate care that could lead to deterioration in their health condition. Findings Included: 1. Record review of Resident #17's admission record dated 03/19/24 revealed an [AGE] year-old resident admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart failure, major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss 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 before2024-03-21 · 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 implement a comprehensive care plan for each resident 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 and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #36 and #38) of 20 residents reviewed for comprehensive care plans. -The facility failed to include care plans for hospice for Resident #36. -The facility failed to include care plans for dialysis for Resident #38. This failure could place resident at risk of not receiving care and services to meet their needs. Finding include: Resident #36 Record review of Resident #36's clinical record revealed an [AGE] year-old female resident admitted to the facility originally on 2-23-2023 and readmitted on [DATE] with diagnoses to include unspecified…
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 before2024-03-21 · 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
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. -LVN failed to don gloves before administering an injectable medication to resident. - Facility failed to keep foley catheter bag off of the floor. These deficient practices have the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, communicable diseases. Findings include: Observation on 03/20/24 at 11:18 AM revealed foley catheter bag hanging from anonymous residents' bed, bottom of the catheter bag was touching the floor, there was no privacy bag on this catheter bag. Observation on 03/20/24 at 12:03 PM revealed LVN A administering insulin to a resident with no gloves on. HH was performed but donning gloves did not take place. Interview on 03/21/24 at 7:26 AM with LVN A was asked what a negative outcome…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-07 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident's representative of the transfer or discharge for 1 (Resident #1) of 5 residents reviewed for transfers/discharges. The facility failed to notify Resident #1's representative of the resident's discharge to the hospital. This failure could affect residents at the facility by placing them at risk of being transferred/discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings include: Record review of Resident #1's face sheet dated 10-7-2023 revealed a [AGE] year-old male resident admitted to the facility originally on 7-16-2023 and readmitted on [DATE] with diagnoses to include acute respiratory failure (occurs when the respiratory system is unable to either adequately absorb oxygen or excrete carbon dioxide), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), hypertension (a condition in which the force of 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 before2023-10-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 (Resident #2) of 5 residents reviewed for physician orders. The facility failed to follow physician orders for completing wound care for Resident #2. The deficient practice could affect residents receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings include: Record review of the clinical record for Resident #2 revealed a [AGE] year-old-male resident admitted to the facility on [DATE] with diagnoses to include multiple sclerosis (a disease in which the immune system eats away a the protective covering of nerves), sciatica (pain radiating along the sciatic nerve, which runs down one or both legs from the lower back), fall, pain, hypertension (a condition in which the force of the blood against the artery walls is too high), and diabetes (a chronic condition…
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.
- No harm found · C2026-07-01 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to conduct and document a comprehensive facility-wide assessment for the past year to determine what resources were necessary to care for its residents competently during day-to-day operations and review and update the assessment at least annually for 1 of 1 facility reviewed. The Facility Assessment had not been updated since January 2025. This failure could place residents at risk of their needs going unmet and result in a lack of services provided by the facility to competently care for all residents.The findings included: Record review of the Facility Assessment revealed the last documented review and update occurred in January 2025. During an interview on 06/30/26 at 1:59 PM, the AIT stated she had served in that role since July 2025. She stated she had not reviewed the Facility Assessment since assuming the position because she had not had time but stated it had been updated before the previous survey. The AIT stated it was her responsibility along with the ADM to update the Facility Assessment and acknowledged it…
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
$19,190 in federal fines across 1 penalty.
- $19,190 — penalty dated 2024-09-20
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| CHUMLEY, RICHARD | Individual | CORPORATE DIRECTOR | since 05/01/2007 |
| REINART, JANET | Individual | CORPORATE DIRECTOR | since 05/01/2010 |
| WRIGHT, CECIL | Individual | CORPORATE DIRECTOR | since 09/16/2014 |
| SKYBLUE HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 02/15/2019 |
| GANZ, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/01/2018 |
| LARA, SERGIO | Individual | ADP OF THE SNF | since 02/20/2025 |
| SULLIVAN, BRYAN | Individual | ADP OF THE SNF | since 02/14/2025 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
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 455551. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-01, 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.