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Bel Air at Teravista

4105 Teravista Club Drive, Round Rock, TX 78665 · For profit - Corporation · 112 certified beds · (512) 310-3700 Medicare & Medicaid certified

Call the home — (512) 310-3700 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation2 immediate-jeopardy citations CMS recorded as corrected before the inspection ended (past non-compliance)$19,188 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • it has 1 actual-harm citation
  • inspectors recorded 2 serious findings 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $19,188 in federal fines (most recent 2025-01-14)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 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

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
425 University Blvd · (512) 509-0200 · Call to confirm hours
Pharmacy
Cvs0.7 mi
501 University Blvd · (512) 310-8791 · Call to confirm hours
Grocery
1900 University Blvd · (512) 843-4250 · Call to confirm hours
Park
4201 Teravista Club Dr · Typically dawn to dusk
Place of worship
1221 Satellite Vw · (512) 926-4272

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
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.5%15.8%15.4%better
Long-stay residents who lose too much weight4.3%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.5%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.6%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.5%3.3%3.3%better
Long-stay residents whose ability to walk worsened8.4%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication7.2%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers4.0%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control8.7%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table3.7%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.1%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine99.5%88.0%79.4%better
Short-stay residents rehospitalized after admission25.7%25.7%22.6%worse
Short-stay residents with an outpatient ER visit8.2%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days1.452.171.67better
Long-stay outpatient ER visits per 1,000 resident days0.212.061.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

57.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 342 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.5%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
52.2%U.S. median 56.6%
Met the expected recovery
0.48U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.20hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 52.2% 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 161 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 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF57.5%CMS range 51.9–61.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 8.2–13.110.7%Oct 2022–Sep 2024no 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 discharge52.2%56.6%Oct 2024–Sep 2025CMS 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 discharge47.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge52.8%50.0%Oct 2024–Sep 2025CMS 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 identified98.5%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 discharge97.3%98.7%Oct 2024–Sep 2025CMS 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 stay0.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 4.5–9.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.051.02Oct 2022–Sep 2024CMS 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

0.67
RN hours/ resident / day
0.74
LPN hours/ resident / day
1.97
Aide hours/ resident / day
3.38
Total nurse hours/ resident / day
0.62
RN hoursweekends
42.9%
Total nursing turnover
22.2%
RN turnover

How full it usually is: this home is certified for 112 beds and averages 101.7 residents a day — about 91% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.38 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 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 3.02 hrs/resident/day on weekends vs 3.52 on weekdays — 14% thinner on weekends. RN hours go from 0.69 to 0.62 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%.

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

6
deficiencies at the latest standard inspection (2026-06-04)
3
at the previous standard inspection (2025-04-10)

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.

ABCDEFGHIJKL

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.

23 citations, most serious first. The 13 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-01-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 interviews and record reviews the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being transferred for 1 of 7 residents reviewed for accidents and hazards. CNA A failed to transfer Resident #1 received assistance with the mechanical lift on 12/14/2024. This failure could result in residents receiving injuries. The noncompliance was identified as PNC. The IJ began on 12/14/24 and ended on 12/16/24. The facility had corrected the noncompliance before the survey began. Findings included: Record review of Resident #1's Face sheet dated 12/31/2024 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cognitive communication deficit (problems with communication), pressure ulcer of right heel (wound on heel), dysphagia (difficulty swallowing), difficulty walking, repeated falls, lack of coordination, osteoarthritis (joint disease), cerebrovascular disease (a range…

    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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Immediate jeopardy · Jcited before2024-08-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not elope from the facility on 08/22/24. She was found less than two hours later approximately one mile away at a gas station on a busy street. She had a fall which resulted in a swollen face and a cheek abrasion. This noncompliance was identified as PNC IJ. The deficient practice began on 08/22/24 and ended on 08/23/24. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for, falls, injuries, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including cognitive impairment, 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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · G2026-06-04 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such 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 observation, interviews, and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards or practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 (Resident # 128) residents reviewed for pain management. The facility failed to administer pain medication to Resident #128, who had pancreatic cancer, from the time she was admitted [DATE] at 7:30 p.m. to 6/2/26 at 10:00 a.m. This failure could place the residents at risk of delayed healing, physical, mental, and psychological distress.Findings included: Record review of Resident #128's face sheet, dated 06/03/2026, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of malignant neuroendocrine tumors (pancreatic cancer), secondary malignant neoplasm (cancerous tumor) of liver and intrahepatic bile duct (a network of tiny, branching tubes located inside the liver), and pain. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-04 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 3 of 10 residents (Resident #13, Resident #48, and Resident #86) reviewed for ADL care. The facility failed to ensure, Resident #48, and Resident #86 did not have unwanted facial hair.The facility failed to ensure Resident #13 was changed or toileted every two hours. This failure could place residents at risk of embarrassment and diminished quality of life.Findings included: 1. Record review of Resident #13's face sheet, dated 06/03/2026, reflected an [AGE] year-old female admitted on [DATE]. Resident #13 had diagnoses which included: traumatic subdural hemorrhage without loss of consciousness (blood collects between the brain and the skull's outermost protective covering following a head injury), history of falling and syncope (fainting or passing out.) chronic…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-04 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide 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, based on the comprehensive assessment of the resident, that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 3 of 7 residents (Resident #28, Resident #13, and Resident #127) reviewed for quality of care. The facility failed to ensure: Nursing staff weighed Resident #13 and Resident #127 every day according to their care plan and physician's orders due to their CHF diagnosis. Nursing staff provided wound care for Resident #28 according to her care plan and physician's orders. These failures could place the residents at risk of fluid overload, infection, and hospitalization.Findings included. 1.Record review of Resident #13's face sheet, dated 06/03/2026, reflected [AGE] year-old female admitted on [DATE] with diagnoses that included: traumatic subdural hemorrhage without loss of consciousness (blood collects…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-04 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for all residents who consumed foods orally from the only kitchen in the facility that: The facility failed to provide palatable food that was attractive or appetizing to residents who complained the food did not look or taste good and that it was frequently cold. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, food borne illnesses, and diminished quality of life.During an interview on 06/02/2026 at 1:05 p.m., it was revealed that Resident #18's only complaint was that her soup was too salty. During an interview on 06/02/2026 at 3:29 p.m., Resident #17 stated his meals were served cold almost every day. The resident stated he ate in his room daily. The resident stated his meals were rarely ever hot or warm enough. During an interview on 06/02/2026 at 3:34 p.m., Resident #118 stated her meals were served cold often.…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-06-04 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services.The facility failed to ensure dietary staff followed proper handwashing and glove use.These deficient practices could place residents at risk for food borne illness.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 and Nutrition Services.The facility failed to ensure dietary staff followed proper handwashing and glove use.These deficient practices could place residents at risk for food borne illness.The findings were:During an interview on 06/02/2026 at 9:11 a.m., it was revealed that DA Q has been employed at this facility since March of 2026, she has a current Food Handlers Certificate, and she has been…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-06-04 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 5 of 12 residents (Resident #128, Resident #90, Resident #41, Resident #37, and Resident #60) reviewed for infection control. Facility failed to ensure: TN L sanitized the over-the-bed table prior to setting supplies on it for Resident #90's wound care, did not put on PPE (gown) before providing care to Resident #128 and Resident #90 and did not sanitize her hands two times between changing gloves during Resident #90's wound care. MA D sanitized her hands between changing gloves after performing eye drops for Resident #60 and failed to sanitize the blood pressure cuff between Resident #37 and Resident #41. These failures could place the residents at risk of infection transmission, sepsis, and hospitalization. Findings included: 1.Record review of Resident #128's face sheet, dated 06/03/2026, reflected a [AGE]…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-01 · tag F0552 — isolated
    Ensure 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 interviews and record reviews, the facility failed to ensure the resident had the right to be informed of, his or her treatment which includingrights.ht to be informed in advance, by the physician or other practitioner or professional, of the risk and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 5 residents (Resident #1) reviewed for resident rights .The facility failed to provide information to Resident #1's FM about the change of medication from Lantus (Insulin) to Metformin and its risks and benefits and other alternative options available.This failure could place residents at risk of receiving medications without their prior knowledge or consent.The findings include:Record review of Resident #1's face sheet dated 04/01/26 revealed a [AGE] year-old male admitted on [DATE]. His diagnoses were dementia, dysphasia (swallowing difficulty), type 2 diabetes, pain, hypothyroidism (Low thyroid…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-12 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure 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 observations, interviews, and record reviews, the facility failed to ensure residents were free from significant medication errors for 1 of 2 residents (R #1) reviewed for medication administration.The facility failed to administer R#1's physician ordered 4 units of Insulin Lispro Injection solution, prescribed to treat Type 2 Diabetes Mellitus, (elevated blood sugar levels) on 12/19,12/22,12/23,12/24,12/25,12/28,12/29 and 12/30/2025. These deficient practices placed residents at risk for not receiving the therapeutic effects of their prescribed medications.Findings include: Record review of R1's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. R1 had diagnoses which included TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (elevated blood sugar levels), HYPOTHYROIDISM (when the thyroid gland doesn't make enough thyroid hormone), BIPOLAR DISORDER (a condition that causes extreme mood swings). ANXIETY DISORDER (Characterized by feelings of fear or apprehension…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-12 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 residents (R#2), reviewed for pharmaceutical services, in that:The facility failed to ensure Resident #2 had her physician ordered Robaxin (muscle relaxer) 1 500 mg tablet by mouth every 8 hours for pain, available on 01/10/2026.This failure could place residents at risk for not receiving medication as ordered. Findings included: Review of Resident #2 admission record dated 01-08-2026 revealed a [AGE] year-old female that was admitted to the facility on [DATE]. Her diagnoses included Type 2 Diabetes, Chronic kidney disease, Nonalcoholic cirrhosis of the liver (Chronic inflammation of the liver causing gradual scarring), Compression Fracture of the Lumbar Vertebra, (vertebra collapse due to excessive pressure), Malignant breast cancer (producing…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-11-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide 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 needed respiratory care were provided with such care, consistent with professional standards of practice, for 5 of 7 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for quality of care.The facility failed to ensure Resident #1, Resident #2 , Resident #3, Resident #4, Resident #5's nebulizing masks and/or oxygen canulas were bagged for sanitation when not in use on 11/06/25.This failure could place residents at risk for respiratory infections. The findings included:Record review of Resident #1's face sheet, dated 11/06/25, revealed a [AGE] year-old male, admitted on [DATE]. His diagnoses were multiple fractures of ribs, pulmonary embolism (block by blood clot in lung's artery), Parkinson's disease (kind of neurological disorder), acute respiratory failure with hypoxia (less oxygen), abnormalities of gait and mobility and muscle wasting and atrophy. Resident #1 was sent…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-09 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 interviews and record reviews, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status for 1 (Resident #1) of 5 residents review for resident rights. RN A failed to notify Resident #1's family when a new medication order for antibiotics, to treat a urinary tract infection, was initiated on 06/14/2024. This failure put residents at risk for not having their representative notified and aware of their current medical status. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included retention of urine unspecified, pain unspecified, dementia (a general term for a decline in cognitive function that interferes with daily life) in other disease classified elsewhere, acute kidney failure (a sudden and rapid decline in 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · E2025-05-19 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay and final status of discharge for three of three (Resident #1, Resident #2, Resident #3) reviewed for discharge summary. The facility failed to complete a discharge summary and recapitulation for Resident #1, Resident #2 and Resident #3. This failure could place residents at risk of not having complete records, necessary services, or information after permanent discharge from the facility. Findings included: Review of Resident #1's face sheet dated 05/19/2025 revealed an [AGE] year-old man admitted on [DATE] and discharged on 04/30/2025 with diagnoses of erosive (osteo) arthritis (severe form of joint inflammation and bone erosion in hand), muscle weakness, cognitive communication deficit (problem with communication that results in impaired thought processes), mild cognitive impairment (condition where a person experiences more memory or thinking problems than…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-10 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide 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 observations, interviews, and record review, the facility failed to provide routine and/or emergency drugs and biologicals to its residents for three of (Resident #21, Resident #345, and Resident #90) four residents reviewed for pharmacy services. The facility failed to ensure Resident #21, Resident #345, and Resident #90's antibiotic medicine were administered daily as ordered. The facility failed to administer antibiotic medicine 02 times and at the correct time 21 times for Resident #21. The facility failed to administer antibiotic medicine 04 times for Resident #345. The facility failed to administer antibiotic #1 medicine 01 time and at the correct time 06 times for Resident #90. The facility failed to administer antibiotic #2 medicine at the correct time 16 times for Resident #90. This failure could place residents at risk of not receiving necessary preventative measures and adversely affect a resident's condition. Findings include: Review of Resident #21's face sheet revealed a [AGE] year-old…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 following professional standards for food service safety for 1 of 1 kitchen that was reviewed for kitchen sanitation in that: - Food items were not labeled and/or dated. Some food items were not labeled at all. - The grease in the fryer was dirty. - Drawers where the serving utensils were stored were not clean with debris in in the drawer. - Staff serving food in hall 100 were not sanitizing their hands before getting food trays to take to the resident. These failures could place all residents who received meals from the main kitchen at risk for food-borne illness. Findings include: Observation on 4/08/2025 at 9:15 am of the walk-in refrigerator reflected the following: - Lemons in a box were dated 3-17-2025 with no discard date. - Lemonade in a serving container dated 2-10-2025 was expired. - Lettuce dated 4-7-2025 with no discard date. - Cucumbers in a box dated 3-10-2025 with no discard date. - Raw meat in a pan covered in plastic dated 4-6-2025 with no discard…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-10 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the drug regiment review recommendations from the pharmacy consultant were received and acted upon for 1 (Resident # 144) of 4 residents reviewed for drug regimen review. The facility failed to follow their policy regarding the pharmacy consultant and did not follow up on new admission pharmacy consultant recommendations dated 3/28/25. These failures could place residents being at risk for medication errors, unnecessary medications, and incorrect administration. Findings included: Review of Resident # 144's admission record dated 4/10/25 reflected an [AGE] year-old female admitted on [DATE]. Resident #144 had diagnoses of traumatic subdural hemorrhage with loss of consciousness of unspecified duration (brain bleed with loss of loss of consciousness), fracture of sacrum (fracture of bone that connects the spine to the pelvis), type 2 diabetes (a long term condition in which the body has trouble controlling blood sugar levels), muscle weakness,…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-14 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) for 1 (Resident #2) of 1 reviewed for pharmaceutical services. MA D left Resident #2's medications with her and walked out without observing Resident #2 taking the medications. This failure could place residents at risk for not receiving a therapeutic effect or another resident getting the medication. The findings were: Record review of Resident #2's face sheet dated 12/31/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of fracture, pain, heart disease, sleep disorder, muscle spasm, injury of head, weakness and gastroesophageal reflux disease without esophagitis (reflux). Record review of Resident #2's admission MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Record review of Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-06 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each 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 observation, interview, and record review the facility failed to provide services in the facility with reasonable accommodation of resident needs and preferences by not ensuring the resident call system was accessible to 3 (Resident #1, Resident #2, and Resident #3) of 6 residents reviewed for call systems. - Resident call system was not accessible for Resident #1, Resident #2, and Resident #3. This failure could endanger the health or safety of the resident or other residents if they are not able to call for assistance when needed. Findings include: Review of the undated face sheet for Resident #1 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of aftercare following surgery for malignant neoplasm of pancreas (pancreatic cancer), diabetes mellitus type 2, hypertension, pain, and diarrhea. Review of the admission MDS assessment for Resident #1 dated 05/05/24 did not reflect a BIMS score. Section GG reflected Resident #1 needed partial assistance from another person to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-14 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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 ensure the residents' had the right to a safe, clean, comfortable and homelike environment, which included but not limited to receiving treatment and supports for daily living safety for 6 residents (Residents #9, #29, #40, #57, #61 and #68) of 20 residents reviewed for resident rights. The facility failed to ensure resident room water temperature was maintained at a comfortable warm temperature which was at least 100 degrees F. This failure could place residents at risk for living in an uncomfortable, and unhomelike environment which could cause a diminished quality of life. The findings include: 1. Record review of Resident #9's clinical record reflected Resident #9 was [AGE] year-old male who was admitted to the facility on [DATE]. Resident #9 had diagnoses which included Parkinson's (disorder of central nervous system affects movement)and muscle weakness. Record review of Resident #9's MDS quarterly assessment, completed 2/16/24,…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 safety in the facility's only kitchen. 1. The facility failed to ensure food items in the facility's only dry storage were dated and sealed appropriately. 2. The facility failed to ensure food items in the facility's only walk in freezer were dated and sealed appropriately. 3. The facility failed to ensure staff wore proper hair or beard coverings. These failures could place residents at risk for food-borne illness, and food contamination. Findings include: Observations of the facility's kitchen's only dry storage on 03/12/24 at 08:51 AM revealed the following items were not sealed or dated: - in the freezer a box of fish fillet was opened and undated - in the dry storage was one container of thick and easy was opened and undated - in the dry storage was one bag of grits was opened and undated, and not in a sealed bag. During an observation of lunch being plated on 03/12/24 at 11:40 AM revealed [NAME] D did not have…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 2 of 4 residents (Resident # 6 and Resident #75) reviewed for infection control. - LVN B failed to don gloves while assisting Resident #75 with a PICC dressing change. - RN C failed to maintain a sterile field while performing a PICC dressing change for Resident #75. - LVN E failed to perform hand hygiene after changing her gloves failed to change her gloves after they became contaminated and failed to maintain a sterile field during a catheter change for Resident #6. - CNA F failed to change her gloves after they became contaminated while performing perineal care for Resident #6. These failures could place residents at risk for cross contamination and the spread of infection. The findings include: Resident #6 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-21 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 safety in the facility's only kitchen. The facility failed to ensure: The food items in the walk-in refrigerator in the kitchen were labelled and dated. The cans stored in the dry storage area in the kitchen were not dented. These failures could place residents at risk for food-borne illness, and food contamination. Findings included: Interview and observation of the walk-in refrigerator in the kitchen on 08/21/23 beginning at 11:00 AM revealed the following items had no name and/or prepared and 'use by' dates on them: 1. One plastic bag contains cooked bacon. 2. Three packets of ham. 3. One large plastic bag of a white hollow substance. The DM identified it as cooked pasta. 4. One plastic bag and two containers of yellow substance. DM identified it as scrambled egg. 5. One container of light brown substance. DM identified it as tuna. 6. One container of brown cubes. DM identified it as beef chunks. 7. Two containers of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$19,188 in federal fines across 2 penalties.

  • $10,361 — penalty dated 2025-01-14
  • $8,827 — penalty dated 2024-08-24

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 CANTEX CONTINUING CARE — 37 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 →

RatingThis homeChain avg
Overall 3 of 53.1-0.1 vs chain
Health inspection 2 of 52.9-0.9 vs chain
Staffing 3 of 51.9+1.1 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 36 homes this chain runs (chain average 3.1★, per CMS)
1 of 5The Carlyle at Stonebridge ParkSouthlake, TX 1 of 5The Colonnades at Reflection BayPearland, TX 1 of 5The CrescentSugar Land, TX 2 of 5Ashford GardensHouston, TX 2 of 5Magnolia ManorGroves, TX 2 of 5Palomino PlaceMesquite, TX 2 of 5Park Valley Inn Health CenterRound Rock, TX 2 of 5San RemoRichardson, TX 2 of 5SorrentoSan Antonio, TX 2 of 5Sundance Inn Health CenterNew Braunfels, TX 2 of 5The Villa At Mountain ViewDallas, TX 2 of 5Windemere At Westover HillsSan Antonio, TX 2 of 5Windsor GardensLancaster, TX 3 of 5Fort Bend Healthcare CenterRosenberg, TX 3 of 5HollymeadFlower Mound, TX 3 of 5LarkspurLufkin, TX 3 of 5Mill CreekSilsbee, TX 3 of 5Prairie EstatesFrisco, TX 3 of 5Renaissance Care CenterGainesville, TX 3 of 5Solera at West HoustonHouston, TX 3 of 5The Bradford At BrooksideLivingston, TX 3 of 5The Broadmoor at Creekside ParkThe Woodlands, TX 3 of 5The Harrison at HeritageFort Worth, TX 3 of 5The Manor at SeagovilleSeagoville, TX 4 of 5Beacon HillDenison, TX 4 of 5CarraraPlano, TX 4 of 5Oakwood Manor Nursing HomeVidor, TX 4 of 5The Belmont At Twin CreeksAllen, TX 4 of 5The Madison on MarshCarrollton, TX 4 of 5Woodville Health And Rehabilitation CenterWoodville, TX 5 of 5Bonne ViePort Arthur, TX 5 of 5Coronado At Stone OakSan Antonio, TX 5 of 5Crestview CourtCedar Hill, TX 5 of 5Laurel CourtAlvin, TX 5 of 5Palma RealMathis, TX 5 of 5Riverside OaksVictoria, TX

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 / managerTypeRoleSince
HOOPER, GRADYIndividualCORPORATE OFFICERsince 12/01/2015
BEL AIR CONTINUING CARE CENTER LTD COOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2025
NEWMAN-BEAVER, HEATHERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/28/2024
RAPOLU, PRAVEENIndividualADP OF THE SNFsince 06/15/2022

CMS files one row per role, so the 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$10.4M
Net patient revenuemost recent cost report
-0.2%
Operating marginrevenue minus expenses
$1
Related-party expense0% of expenses
Who pays — share of resident-days
Medicaid 45%Medicare 20%Other / private 36%

This home reported $1 paid to related parties (affiliated landlords or management companies) in its most recent 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

$340per resident / day
operating cost
$10,340per month
≈ monthly operating cost
$339per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

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 676345. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-04, 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.

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