Quitman Wellness & Rehabilitation
1026 E Goode St, Quitman, TX 75783 · For profit - Corporation · 156 certified beds · (903) 763-2284 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- 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
- the CMS record shows $39,049 in federal fines (most recent 2024-10-02)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (81%) runs well above the national median (45%)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 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 | 5 of 5 |
| Long-stay residentspeople who live here | 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 3 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 | 7.8% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.3% | 3.0% | 5.4% | typical |
| 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 | 0.8% | 0.8% | 2.0% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.6% | 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 | 3.0% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.4% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.6% | 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 | 2.0% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 11.7% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.2% | 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 | 96.7% | 88.0% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.87 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 5.60 | 2.06 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
50.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 69 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% 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 | 50.5%CMS range 38.8–59.1 | 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 | 10.5%CMS range 7.0–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 90.9% | 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 | 3.0% | 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 | 7.3%CMS range 3.4–15.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.38 | 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 156 beds and averages 48.5 residents a day — about 31% occupied, or roughly 108 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.74 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 3.10 hrs/resident/day on weekends vs 3.52 on weekdays — 12% thinner on weekends. RN hours go from 0.40 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 81% is well above 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 more than at the previous inspection — worsening. 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 12 most serious are shown; the remaining 16 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-10-02 · 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 each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1 was properly secured in his wheelchair during transport, in which Resident #1 fell forward onto his hands and knees when CNA A hit the brakes on 08/20/2024. The noncompliance was identified as past noncompliance IJ. The noncompliance began on 08/20/2024 and ended on 08/21/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury/death from a vehicle accident and decreased quality of life. Findings Include: Record review of the face sheet dated 10/02/2024, indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] and discharged from the facility on 08/27/2024, with diagnoses including pneumonia, unspecified organism (pneumonia caused by an organism,…
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.
- Immediate jeopardy · Jcited before2024-04-01 · 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 observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 3 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 was adequately supervised after she had a change in mental status and told staff she was leaving the facility, which resulted in her leaving the facility in her wheelchair and going two buildings down the street (on the same side of the road approximately 800 feet) away from the facility on 03/17/2024 without the facility staff's knowledge. An IJ was identified on 04/01/2024. The IJ began on 03/17/2024 and removed on 03/17/2024. While the IJ was removed on 03/17/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because all staff had not been trained on monitoring after a change in condition. This failure could place residents at risk 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 · Ecited before2026-05-06 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on interview and record review, the facility failed to develop and implement a Baseline Care Plan within forty-eight hours of admission that included the instructions for resident care needed to provide effective and person-centered care for 5 of 12 residents reviewed for new admissions. (Resident #15, Resident #64, Resident #47, Resident # 67 and Resident #69). 1. The facility failed to ensure Resident #15, Resident #64, Resident #47, Resident #67, and Resident #69's baseline care plan was completed within 48 hours of admission to the facility. 2. The facility failed to ensure Resident #67's baseline care plan was signed off or reviewed by an RN. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #15's face sheet dated 5/05/26 indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including Non-ST elevation myocardial…
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 · D2026-05-06 · 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 provided care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 19 residents (Resident #47) reviewed for resident rights. The facility failed to ensure Resident #47's catheter drainage bag was in a privacy bag. This failure could place residents at an increased risk of embarrassment and a diminished quality of life. The findings included: Record review of the face sheet, dated 05/06/26, reflected Resident #47 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of zoster (also known as shingles, is a painful, blistering rash caused by the reactivation of the dormant varicella-zoster virus which also causes chickenpox) without complication and urinary retention (holding urine in the bladder). Record review of the admission MDS assessment, dated 04/27/26, reflected Resident #47 had clear speech, was understood by others,…
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 before2026-05-06 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 1 of 5 residents reviewed for the right to be informed. (Resident #47) The facility failed to ensure Resident #47 or her representative provided informed consent prior to taking fluoxetine (an antidepressant medication). These failures could place residents at risk for treatment or services provided without their informed consent. The findings included: Record review of the face sheet, dated 05/06/26, reflected Resident #47 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of zoster (also known as shingles, is a painful, blistering rash caused by the reactivation of the dormant varicella-zoster virus which also causes chickenpox) without complication and major…
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 before2026-05-06 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary clean, comfortable, and homelike environment for 1 of 19 residents reviewed for environment. (Resident #3) 1.The facility failed to replace missing pieces from Resident #3's window blinds. This failure could place residents at risk of an uncomfortable environment and a decrease in quality of life and self-worth.Findings included: 1. Record review of Resident #3's face sheet, dated 5/6/26, reflected she was a [AGE] year-old female, initially admitted on [DATE] and re-admitted to the facility on [DATE]. Her diagnosis included anxiety disorder, muscle wasting and atrophy not elsewhere classified, right shoulder, muscle weakness, need for assistance with personal care, cognitive communication deficit and dementia (a decline in mental ability). Record review of Resident #3's comprehensive MDS assessment, dated 3/23/26, reflected that she had a BIMS score of 9, which indicated moderate cognitive impairment.…
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 · D2026-05-06 · 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 observation, interview, and record review the facility failed to ensure an accurate MDS assessment was completed for 2 of 19 residents (Resident's #11 and #47) reviewed for MDS accuracy. 1. The facility did not ensure Resident #11's admission MDS assessment was accurately coded to reflect her tobacco use. 2. The facility did not ensure Resident #47's admission MDS assessment was accurately coded to reflect her indwelling catheter. These failures could place residents at risk of not receiving care and services to meet their needs.The findings included: 1. Record review of the face sheet, dated 05/06/26, reflected Resident #11 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of benign neoplasm of meninges (slow-growing noncancerous brain tumor) and tobacco use. Record review of Resident #11's smoking assessment, dated 02/20/26, reflected Resident #11 smoked and was safe to smoke with minimal supervision. Record review of the admission MDS assessment, dated…
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 · D2026-05-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 provide the necessary services to maintain personal hygiene for 1 of 24 residents reviewed for ADLs (Residents #54.)The facility failed to provide Resident #54 with a shower the week of 4/27/26-5/03/26.This failure could place residents at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.Findings included:Record review of Resident #54's face sheet dated 5/05/26 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #54 had diagnoses which included Parkinson's disease (movement disorder), right knee pain, difficulty walking, dementia (forgetfulness), chronic pain syndrome and osteoarthritis (degenerative joint disease that breaks down the cartilage and underlying bone, causing pain, stiffness, and reduced mobility).Record review of Resident #54's annual MDS dated [DATE] indicated she…
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 before2026-05-06 · 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 observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 19 (Resident #14) reviewed for adequate supervision and assistive device to prevent accidents. The facility failed to ensure Resident #14 did not use Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) while nasal canula delivering oxygen was in place. These failures could place residents at an increased risk for injury.Findings included: Record review of Resident #14's face sheet dated 5/6/26 indicated Resident #14 was an 82-years-old female initially admitted on [DATE] and readmitted on [DATE] to the facility. Resident #14 had diagnoses including dementia (is a general term for a decline in mental ability severe enough to interfere with daily life), chronic obstructive pulmonary disease with (acute) exacerbation (a progressive, treatable lung disease that restricts airflow, making it hard to breathe) and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 19 (Resident #14) reviewed for medications in room. 1 of 3 medication carts reviewed (Nurse medication cart for the Front Halls) 1.The facility failed to ensure Resident #14 did not have over the counter medication Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) in room on 5/4/26, 5/5/26 and 5/6/26. The facility failed to ensure LVN B secured and locked the nurse medication cart for Front Halls. 2.This failure could place residents at risk of not having their medications available as prescribed or possible drug diversions. Findings included: 1.Record review of Resident #14's face sheet dated 5/6/26 indicated Resident #14 was an 82-years-old female initially admitted on [DATE] and readmitted on [DATE] to the facility. Resident #14 had diagnoses including dementia (is a general term for a decline in mental ability severe enough to interfere 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.
- Potential for harm · E2025-03-19 · 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, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. 1. The facility failed to ensure foods stored in the kitchen walk-in refrigerator were thrown away when expired. 2. The facility failed to ensure foods stored in the kitchen walk-in freezer were thrown away when expired. 3. The facility failed to ensure a mixing bowl with a pink and white substance was labeled and dated. 4. The facility failed to properly store raw meat in the kitchen walk-in refrigerator. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During an observation on 03/17/25 at 09:08 AM, an initial tour of the kitchen was conducted. The following items were observed: 1) 1 mixer bowl half-full of a white and pink frozen substance in the freezer. It was not covered, labeled or dated. 2) 1 container labeled peas in the freezer, dated 02/26/25, expiration date 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 before2025-03-19 · 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 record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet residents highest practicable physical, mental, and psychosocial needs for 1 of 17 residents reviewed for care plans, (Resident #4). Resident #4 was not have a care planned for her DNR (a medical order instructing healthcare providers not to perform CPR or other resuscitative measures if a patient's heart or breathing stops). Her care plan indicated she was a full code. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of the undated face sheet indicated Resident #4 was a [AGE] year-old female that admitted [DATE] and readmitted [DATE]. The face sheet indicated she had diagnoses that included:…
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 16 citations
- Potential for harm · D2024-04-01 · tag F0635 — isolatedProvide doctor's orders for the resident's immediate care at the time the resident was admitted.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have physician orders for the resident's immediate care for 1 of 3 residents (Resident #1) reviewed for admission physician orders. The facility failed to ensure Resident #1 had a physician order to wear her knee brace and to not bear weight on her right knee. This failure could place residents at risk for not receiving appropriate care, treatment, and services. Findings included: Record review of a face sheet dated 03/20/2024 indicated Resident #1 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and wedge compression fracture of T11-T12 vertebra, subsequent encounter for fracture with delayed healing…
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 before2024-02-07 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents had the right to be informed of, and participate in, his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment and treatment alternatives or treatment options to choose the alternative or option he or she preferred for 1 of 4 residents (Resident #58) reviewed for psychoactive medications. The facility failed to obtain an informed consent based on the information of the benefits and risks for Resident #58 prior to administering Seroquel, an antipsychotic, used to treat schizophrenia, bipolar disorder, and depression. This failure could place residents at risk for receiving medications they had not consented to, experiencing potential adverse reactions, and a potential decline in physical and mental health status. Findings included: Record review of Resident #58's face sheet, dated 02/07/2024, indicated an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-07 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment for the front lobby, and 1 of 4 halls ( hall 800) reviewed for a clean and homelike environment. The facility failed to ensure the lobby and hall 800 were without odors. This failure could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings included: During an observation on 02/05/24 at 10:08 a.m., Hall 800 and the front lobby smelled of strong urine. During an observation on 02/06/24 at 8:14 a.m., Hall 800 and the front lobby smelled of strong urine. During an interview on 02/07/24 at 8:54 a.m., LVN E said she had noticed an odor on hall 800 for an unknown amount of time but all staff were aware to try to keep the odor down as much as possible. She said Resident #13 often urinated on himself and staff was supposed to help him every 2 hours to the bathroom. She said the staff was supposed to monitor his room for any urine on the floor and in the bathroom. She said…
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 before2024-02-07 · 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 interviews and record review the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 3 residents (Resident #85) reviewed for baseline care plans. The facility failed to ensure Resident #85 had a baseline care plan completed within 48 hours of admission that included the use of a sling for the diagnosis of displaced fracture of shaft of left clavicle (shoulder). This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of Resident #85's face sheet, dated 02/07/2024 indicated Resident #85 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included sepsis (life threatening complications of an infection), acute cystitis (burning, pain upon urination), metabolic encephalopathy (a problem in the brain caused by chemical imbalance in the blood), acute kidney…
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 before2024-02-07 · 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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 15 residents reviewed for comprehensive care plans (Resident #31 and Resident #24). 1. The facility failed to ensure Resident #31's care plan accurately reflected the use of a sling. 1a. The facility failed to have a physician order for Resident #31's sling to her right arm. 2. The facility failed to ensure Resident #24's care plan reflected she had PTSD (post-traumatic stress disorder that develops in some people who have experienced a shocking, scary, or dangerous event) and her triggers. These failures placed residents at risk of not having their individual care needs met, which could cause a decline in physical health, psychosocial health, and quality of care. Findings included: 1.Record review of Resident #31's face sheet…
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 before2024-02-07 · 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 observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 4 halls (Hall 800) and 1 of 3 shower rooms (Hall 800) reviewed for accidents and supervision. 1. The facility failed to ensure water was at a safe temperature for hall 800. 2. The facility failed to ensure Hall 800 shower room was securely closed and free from hazardous liquid. These failures could place residents at risk of falls, entrapment, burns, or injury. Findings Include: During an observation on 02/05/24 at 10:16 a.m., revealed room [ROOM NUMBER] on hall 800 water in the bathroom sink felt hot to the surveyor's hand. During an observation on 02/05/24 at 10:18 a.m., revealed room [ROOM NUMBER] on hall 800 water in the bathroom sink felt hot to the surveyor's hand. During an observation on 02/05/24 at 10:28 a.m., revealed room [ROOM NUMBER] on hall 800 water in the bathroom…
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 · D2024-02-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 4 (Resident #25) who were reviewed for respiratory care. 1. The facility failed to ensure Resident #25 had an oxygen sign placed on her door. 2. The facility failed to ensure Resident #25's nasal cannula tubing was dated and, in a bag, when not used. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #25's face sheet, indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), chronic obstructive pulmonary disease {COPD}(a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-07 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 6 residents (Resident #24) reviewed for trauma-informed care. The facility did not ensure Resident #24's trauma screening was completed upon admission to the facility. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization. Findings included: Record review of Resident #24's face sheet, indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included PTSD (intense, disturbing thoughts and feelings related to their experience that lasted long after the traumatic event has ended), Depression( a mood disorder that causes 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 before2024-02-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 15 residents reviewed in sample (Resident #21). The facility failed to ensure Resident #21's Ziploc bag with 2 Vitamin D(cholecalciferol) 1000units(25mcg) tablets and 1 bottle of benzocaine topical anesthetic spray 20% were stored and locked in an area not accessible to other staff, residents, or visitors. This failure could place residents at risk of injury. Findings included: Record review of Resident #21's face sheet dated 02/07/24 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of Parkinson's disease(chronic degenerative disorder of the central nervous system), myocardial infarction(heart attack), kidney failure, high blood pressure, and gastrostomy tube(medical device used to provide nutrition for people who cannot obtain nutrition by mouth). Record review 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 · D2024-02-07 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #20) reviewed for hospice services. The facility did not ensure Resident #20's hospice records were a part of their records in the facility. This could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of a face sheet dated 02/07/2024, indicated Resident #20 was a [AGE] year-old female initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included Alzheimer's Disease (a progressive disease 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 · D2024-02-07 · 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 diseases and infections for 1 of 3 residents (Resident #12) reviewed for infection control practices. The facility failed to ensure LVN G performed hand hygiene between glove changes while providing wound care to Resident #12. This failure could place residents and staff at risk for cross contamination and the spread of infection. Findings included: Record review of Resident #12's face sheet dated 02/07/24 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses cerebral palsy (a congenital disorder of abnormal movement, muscle tone, or posture), high blood pressure, cognitive communication deficit (difficulty with thinking and use of language), urinary tract infection, and depression. 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 · D2024-02-07 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolatedHave policies on smoking.
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 follow their own established smoking policy for 2 of 4 residents (Resident #13 and Resident #85) reviewed for smoking. 1.The facility failed to follow the policy on smoking by not completing a smoking screen assessment quarterly on Resident #13. 2. The facility failed to follow the policy on smoking by not completing a smoking screen on admission for Resident #85 These failures could place residents at risk of unsafe smoking and injury. Findings included: 1.Record review of Resident #13's face sheet dated 01/25/24 indicated Resident #13 was an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Alzheimer's, stroke, and COPD. Record review of Resident #13's Omnibus Budget Reconciliation Act (OBRA)MDS assessment, dated 12/25/23, indicated Resident #13 understood and usually understood. Resident #13's BIMS score was 09, which indicated he was moderately cognitively impaired. 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 · D2024-02-07 · tag F0940 — failed to train staff — isolatedDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 3 of 22 employees (Dietician, Housekeeping Supervisor, and Activity Director) reviewed for required annual trainings. The facility failed to ensure the Dietician and Housekeeping Supervisor received required restraint and the Activity Director received HIV training annually. This failure could place residents at risk for inappropriate restraints and exposure to HIV. Findings included: Record review of the employee files indicated there was no required annual restraint training completed for the following staff: *Dietician hired on 09/20/2022 *Housekeeping Supervisor hired on 10/20/2021 Record review of the employee files indicated there was no required annual HIV training completed for the following staff: *Activity Director hired on 08/01/2021 During an interview on 02/07/2024 at 06:30 p.m., the Human Resource Specialist stated she expected all staff to have the required trainings. The Human…
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 before2024-01-02 · 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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 5 residents reviewed for care plans. (Resident #1) The facility failed to implement the comprehensive person-centered care plan for Resident #1 by not having a fall mat beside the bed when the resident fell. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. Findings include: Record review of a face sheet dated 12/28/23 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (chronic lung disease), heart failure, and anxiety. Record review of the most recent MDS dated [DATE] indicated Resident #1 had a BIMS score of 10 which indicated moderate cognitive impairment. The MDS indicated Resident #1 was dependent on staff for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-02 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to in accordance with accepted professional standards and practices, maintain medical records on each resident that was accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of medical records. The facility failed to ensure LVN A did not falsify Neurological Assessments for Resident #1. This failure could place residents at risk for inaccurate assessments and monitoring. Findings include: Record review of a face sheet dated 12/28/23 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (chronic lung disease), heart failure, and anxiety. Record review of the most recent MDS dated [DATE] indicated Resident #1 had a BIMS score of 10 which indicated moderate cognitive impairment. The MDS indicated Resident #1 was dependent on staff for assistance with ADLs. Record review of a care plan last revised on 12/21/23 indicated Resident #1 was at risk for falls…
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 · D2023-11-29 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
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 specialized rehabilitative services for 1 of 4 residents reviewed for specialized rehabilitative services. (Resident #1) The facility failed to ensure Resident #1 received speech therapy per the PASRR Comprehensive Service Plan January 2023 to March of 2023. This failure could place residents who require specialized rehabilitative services at risk of decline in health status and a decreased quality of life. Findings included: Record review of a face sheet dated 11/28/2023 indicated Resident #1 was an [AGE] year-old female who had a initial admit date of 01/16/2014 readmission to the facility on [DATE]. Her diagnoses included cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), hypertension (high blood pressure), and depressive disorder. Record review on 11/28/2023 of Resident #1's Order Summary dated 11/28/2023 indicated no order for speech therapy. Record review of the MDS dated [DATE] indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$39,049 in federal fines across 2 penalties.
- $14,862 — penalty dated 2024-10-02
- $24,187 — penalty dated 2024-04-01
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to OPCO SKILLED MANAGEMENT — 66 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 | 3 of 5 | 2.3 | +0.7 vs chain |
| Health inspection | 3 of 5 | 2.2 | +0.8 vs chain |
| Staffing | 1 of 5 | 1.7 | -0.7 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 65 homes this chain runs (chain average 2.3★, per CMS)
Showing 40 of 65; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| STRATFORD HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 08/01/2021 |
| CHUMLEY, RICHARD | Individual | CORPORATE OFFICER | — | since 08/01/2021 |
| QUITMAN WELLNESS & REHABILITATION LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/01/2025 |
| GARETZ, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/01/2025 |
| DAVIDOVICH, NIV | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 02/06/2026 |
| HAGINS, ELIZABETH | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 02/06/2026 |
| KAPLAN, ESTHER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 02/06/2026 |
| MINDLE, ADAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 02/06/2026 |
| STERNSHEIN, JENNIFER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 02/06/2026 |
| 1026 E GOODE STREET TX LLC | Organization | ADP OF THE SNF | — | since 11/01/2025 |
| ESDOV INVESTMENTS LLC | Organization | ADP OF THE SNF | — | since 11/01/2025 |
| FIRST SWEETZER HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 11/01/2025 |
| LINZ TRUST | Organization | ADP OF THE SNF | — | since 11/01/2025 |
| PIMENTO PROPERTY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 11/01/2025 |
| RED STONE ADVISORS LLC | Organization | ADP OF THE SNF | — | since 11/01/2025 |
| ROJO RE TRUST | Organization | ADP OF THE SNF | — | since 11/01/2025 |
| LAMBIE, JACOB | Individual | ADP OF THE SNF | — | since 11/29/2023 |
9 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.
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 675553. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-06, 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.