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Trinity Care Center

1000 E Main St, Round Rock, TX 78664 · For profit - Corporation · 179 certified beds · (512) 634-3000 Medicare & Medicaid certified

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Abuse/neglect citations on record (F0600, F0602) — most recent Nov 20252 immediate-jeopardy citations$10,293 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Nov 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,293 in federal fines (most recent 2024-07-18)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 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
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1240 E Palm Valley Blvd · (512) 733-9100 · Call to confirm hours
Pharmacy
901 E Palm Valley Blvd · (512) 248-8742 · Call to confirm hours
Grocery
900 E Palm Valley Blvd · (512) 388-9662 · Call to confirm hours
Park
800 Deerfoot Dr · (512) 218-7030 · Typically dawn to dusk
Place of worship
1201 E Main St

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 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 fell from 2 to 1 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 rating1★
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 increased13.7%15.8%15.4%better
Long-stay residents who lose too much weight6.6%3.0%5.4%worse
Long-stay residents with a catheter left in their bladder0.5%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.6%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 injury7.3%3.3%3.3%worse
Long-stay residents whose ability to walk worsened15.1%14.0%16.1%typical
Long-stay residents on antianxiety or hypnotic medication18.6%18.0%18.9%typical
Long-stay residents given the seasonal flu vaccine98.6%98.0%95.3%typical
Long-stay residents with pressure ulcers1.8%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control15.8%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table7.6%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.9%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine71.2%88.0%79.4%worse
Short-stay residents rehospitalized after admission20.5%25.7%22.6%typical
Short-stay residents with an outpatient ER visit4.0%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days1.312.171.67better
Long-stay outpatient ER visits per 1,000 resident days0.892.061.80better

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.

48.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 79 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.4%U.S. median 51.5%
Got home and stayed home
9.5%U.S. median 10.7%
Went back to hospital
64.0%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 64.0% 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 25 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 SNF48.4%CMS range 39.0–57.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.5%CMS range 6.7–13.810.7%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 discharge64.0%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 discharge60.0%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 discharge44.0%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 identified62.5%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 settingnot 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 dischargenot 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 stay0.0%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 worsened0.0%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 hospitalization6.7%CMS range 4.0–11.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 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

0.29
RN hours/ resident / day
0.78
LPN hours/ resident / day
2.05
Aide hours/ resident / day
3.12
Total nurse hours/ resident / day
0.20
RN hoursweekends
51.3%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 179 beds and averages 146.9 residents a day — about 82% occupied, or roughly 32 beds typically open. It usually has some room. 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 3.12 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.83 hrs/resident/day on weekends vs 3.24 on weekdays — 13% thinner on weekends. RN hours go from 0.33 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% 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

7
deficiencies at the latest standard inspection (2026-01-23)
3
at the previous standard inspection (2024-10-31)

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.

26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · J2024-07-18 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure residents had a right to be free from neglect for 1 (Resident #1) of 6 residents reviewed for neglect. The facility failed to ensure CNA A reported that she observed signs and symptoms of dizziness from Resident #1 before taking her to the shower room on [DATE]. CNA A did not report to anyone what she observed and continued to take Resident #1 to the shower room. While CNA A's back was turned in the shower room to grab something, Resident #1 got up from a shower bench unassisted, fell, and sustained a nondisplaced right inferior pubic ramus fracture and right parietal scalp hematoma with underlying acute traumatic subarachnoid hemorrhage. Resident #1 was sent to the ER and placed on hospice for comfort care. On [DATE], Resident #1 passed away. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:56 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2024-07-18 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental and psychosocial well-being for 1 (CNA A) of 9 CNAs reviewed for competent nursing care. The facility failed to ensure CNA A was proficient in reporting residents' change in condition and resident shower safety. CNA A did not report that she observed Resident #1 having s/s of dizziness and did not have all shower supplies prepared before taking Resident #1 to the shower room. CNA A took Resident #1 to the shower room, turned her back to grab something, Resident #1 got up from the shower bench unassisted and fell in the shower room. Resident #1 was sent to the ER, found to have sustained a nondisplaced right inferior pubic ramus fracture and right parietal scalp hematoma with underlying acute traumatic subarachnoid hemorrhage, 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-23 · 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 and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 (Resident #16, Resident #17, and Resident # 26) of 20 residents reviewed for resident rights.The facility failed to ensure Resident #16, Resident #17, and Resident #26's bedrooms had no scratches or holes on the walls next to their beds.The facility failed to ensure that the walls and carpets in 2 of 3 (200 hall, 400 hall) hallways were in good condition. These failures could place residents at risk of decreased quality of life. Findings included:During an observation on 01/20/2026 at 9:25 AM revealed tattered floors, walls and stains in the carpets of the hallways on 200 hall and 500 hall. The carpets had a foul urine odor to it in the hallways of 200 hall and 400 hall.1. Record review of Resident #26's admission Face sheet, reflected a [AGE] year-old female, admitted to the facility on [DATE], with a diagnoses of hypertensive heart disease without heart failure (structural 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-23 · 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 residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of ten residents (Resident #32, Resident #100, and Resident #113) reviewed for ADLs. The facility failed to ensure Resident #113's fingernails were trimmed and clean. The facility failed to ensure Resident #32's and Resident #100's facial hair was shaved. These failures could place residents at risk of not receiving care services, diminished quality of life, and decreased self-esteem.Findings included: 1. Record review of Resident #32's face sheet, dated 01/21/2026, revealed an [AGE] year-old female, admitted [DATE], diagnoses included chronic venous hypertension (condition of sustained high blood pressure in leg veins caused by damaged valves or, less commonly, venous obstruction, leading to blood pooling), major depressive disorder (severe mental health condition marked by…

    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 · E2026-01-23 · 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 observation, interview and record review, the facility failed to establish a system of accurate reconciliation and determine that drug records were in order, and that an account of all controlled drugs were maintained and periodically reconciled for 3 of 6 medication carts ( RN G's Medication Cart #1, RN H's medication cart #2, and RN I's Medication Cart #3) in the facility effecting 3 residents (Resident #5, Resident #55, and Resident #148) reviewed for pharmacy services.1. The facility failed to ensure RN G accurately reconciled Resident #5's narcotic medication log when she administered but did not sign for Resident #5's Lorazepam (controlled medication used for anxiety) 1 tablet and Acetaminophen/APAP (controlled medication used for pain) 1 tablets on 01/22/2026 at 8:48 a.m.2. The facility failed to ensure RN H accurately reconciled Resident #55's narcotic medication log on the medication cart 2 by omitting the count of Resident #55's morphine sulfate (controlled medication used for pain 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-23 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. There were 15 errors in 43 opportunities resulting in a 34.88% error rate, which involved 3 of 5 residents (Resident #70, Resident #109, and Resident #114) and 2 of 3 staff (MA C and MA D) observed during medication administration reviewed for medication errors.MA D failed to administer Spironolactone 25 mg (treating high blood pressure) ordered by physician for Resident #70. MA C failed to administer Namenda 5 mg (treating moderate to severe dementia) as ordered by physician for Resident # 114.MA C administered Resident #109's 13 medications outside of the allotted time frame. These failures could place residents at risk of their medications not being administered according to Physician's orders, getting their medications late, or not receiving the intended therapeutic benefits of their medications.Findings included: During observation of the medication pass on 01/21/2026 at 7:44 a.m., MA D…

    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 before2026-01-23 · 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 service safety for one of one kitchen reviewed for sanitation. 1.The facility failed to ensure sanitation practices including cleaning the ice machine, cleaning the juice dispenser nozzle, cleaning the front of the convection oven, and cleaning the dish rack storage cart.2. The facility failed to label and date all food items in the kitchen.3. The facility failed to properly cover all food items to prevent contamination.These failures could place residents at risk of foodborne illness.Findings Included: During an observation on 1/20/26 at 9:22 a.m., revealed a container of spaghetti meat sauce and a container of winter vegetable blend on stovetop griddle uncovered. This should be covered to prevent cross contamination from a physical contaminant. During an observation on 1/20/26 at 9:23 a.m. revealed a bag of corn chips undated, unlabeled, and not closed securely. Further observation revealed a bag of oatmeal…

    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 · E2026-01-23 · 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 observations, interviews, 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 9 of 15 residents (Resident #18 and 8 residents in the dining room near nursing station C) reviewed for infection control.1. CNA E did not change gloves between dirty and clean peri-care tasks and did not sanitize her hands between glove changes during peri-care for Resident #18.2. CNA F and RN G did not sanitize their hands between passing meal trays for 8 residents in the dining room near nursing station C. These failures could place the residents at risk of infection transmission, sepsis, and hospitalization.Findings included: An observation on 01/22/2026 at 12:18 p.m. of peri-care for Resident #18, revealed CNA E did not change her gloves after cleaning dirty peri-care area with bowel movement and front peri-care area. CNA E changed her gloves without conducting hand hygiene. CNA E touched bedside table,…

    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 · D2026-01-23 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 each resident has the right to secure and confidential personal and medical records for 1 of 15 residents (Resident #87) reviewed for Privacy and Confidentiality. The facility failed to ensure Resident #87's clinical records were protected from being viewed by unauthorized persons when LVN J left Resident #87's personal information visible on the computer's screen on unattended medication cart. This failure could place residents' personal information at risk of being exposed to unauthorized individuals. Findings included:Observation on 1/21/2026 at 4:24 p.m., revealed the computer screen on LVN J's medication cart on side C was open and unlocked, with Resident #87's MAR information displayed and visible to unauthorized individuals, including visitors or other residents not observed at that time near that cart.During an interview on 1/21/2026 at 4:26 p.m., with LVN J, she stated she was in-serviced on HIPAA a few months ago via…

    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 · D2025-11-19 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents had the right to be free of misappropriation of resident property and exploitation for 1 of 2 residents (Resident #1) reviewed for misappropriation and exploitation.The facility did not prevent misappropriation when on 11/04/2025 CNA A accessed Resident #1's personal cell phone and used Resident # 1's mobile cash application to transfer amounts of $ 31.00 and $50.00 to herself. This failure could place residents at risk of misappropriation of money, possessions, and feelings of loss.Record review of the facility provider investigation report written by the facility ADM, dated 11/05/2025, reflected: Resident #1 was a [AGE] year-old woman who resided at the facility for Rehabilitation care services. Resident # 1 reached out to facility letting the facility know that Resident #1's cell phone cash application was used to make payments to CNA A on 11/04/2025 at 7:15 PM. The facility started an investigation of the incident and filed 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-07-09 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 18 residents (Resident#1, Resident #3, and Resident #4) reviewed for dignity. The facility failed to ensure catheter bag was covered and not visible Resident#1, Resident #3, and Resident #4. This failure placed residents at risk of embarrassment and diminished quality of life. Findings included: Record review of Resident#1's admission Record updated 7/9/25 revealed, Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnosis of nontraumatic intracerebral hemorrhage (stroke), acute respiratory failure (difficulty breathing), dysphagia following cerebral infarction (difficulty swallowing after stroke).Record review of Resident#1's care plan updated 7/8/25 revealed, IN INTERVENTION: The resident requires SKIN inspection per…

    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 · E2025-07-09 · 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 observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for three (Resident #1, Resident #2, and Resident #17) of 18 residents reviewed for resident call system in that: The facility failed to ensure call lights were within reach for Resident #1, Resident#2, and Resident #17.This failure could have placed residents at risk of being unable to obtain assistance when needed Findings included:Record review of Resident#1's admission Record updated 7/9/25 revealed, Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnosis of nontraumatic intracerebral hemorrhage (stroke), acute respiratory failure (difficulty breathing), dysphagia following cerebral infarction (difficulty swallowing after stroke).Record review of Resident#1's care plan updated 7/8/25 revealed, Problem: The resident has an ADL self-care performance deficit r/t CVA with hemiplegia of left side…

    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 14 citations
  • Potential for harm · E2025-07-09 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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 observation, interview, and record review the facility failed to ensure maintain medical records on each resident that are- Complete and accurately documented, for 3 (Resident #1, Resident #9, and Resident #10) of 5 residents reviewed for assessments in that: -The facility did not ensure Resident #1, Resident #9, and Resident #10's wound assessments accurately reflected current wound locations, measurements, or wound typeThis failure could place residents needing wound care at risk of not receiving proper care, treatments, and interventions.Findings included:Record review of Resident#1's admission Record updated 7/9/25 revealed, Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnosis of nontraumatic intracerebral hemorrhage (stroke), acute respiratory failure (difficulty breathing), dysphagia following cerebral infarction (difficulty swallowing after stroke).Record review of Resident#1's care plan updated 7/8/25 revealed, IN INTERVENTION: The resident requires SKIN…

    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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-18 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 16 (Resident #1 and Resident #2) residents reviewed for accommodation of needs. 1. The facility failed to provide a working communication system, which was easily at reach at the bedside, which would allow Resident #1 to call for assistance. From 06/10/25 until 06/18/25, Resident #1 did not have a working communication system in her room. 2. The facility failed to provide a working communication system for Resident #2 on 06/18/25 when her call light was broken. These failures could place residents at risk of not having a means of directly contacting caregivers in an emergency, a delay in assistance, a decreased quality of life and a loss of dignity. Findings included: 1. 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-10-31 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 observations, interviews, and record reviews, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to label and date all food items located in the reach-in refrigerator, walk-in refrigerator, and walk-in freezer on 10/29/2024, 10/30/2024, and 10/31/2024. 2. The facility failed to effectively reseal all food items in the walk-in refrigerator and walk-in freezer to prevent contamination or spoilage on 10/29/2024, 10/30/2024, and 10/31/2024. 3. The facility failed to dispose of expired foods items located in the walk-in refrigerator. 4. The facility failed to clean the ice machines properly resulting in the presence of slime and an unidentified black substance build up in the ice machines on 10/29/2024 and 10/30/2024. 5. The facility failed to ensure kitchen staff held cold foods (fortified vanilla pudding and fruit cups) at a temperature of 41 degrees Fahrenheit or less on 10/30/2024. 6. The facility failed to ensure 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-31 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 for 1 of 1 resident (Resident #102) reviewed for care plans. The facility failed to ensure Resident #102 had a care plan that reflected her new 7/8/24 diagnosis of unspecified convulsions (seizures). This failure could cause the staff to miss needed safety measures on the resident and place the resident at risk of injury from seizures. Findings include: Record review of Resident # 102's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Diabetes, Hypertension (high blood pressure), Reflux, Dysfunction of Bladder and High Cholesterol. The face sheet also revealed a new diagnosis of Unspecified Convulsions with an onset date of 7/8/24. Record review of Resident #102's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, which indicated the resident's cognitive ability was severely impaired. The MDS did list Seizure Disorder or…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-31 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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, functional, sanitary, and comfortable environment for residents, staff, and the public for one of one facility reviewed for environment in that: 1. The facility failed to properly maintain sanitary emergency eyewash station in the kitchen when the protective eyewash covers were not properly positioned, not capped when not in use, and had a roll of paper towels inside the basin. The facility failed to keep the area clear and accessible to kitchen staff when the area was cluttered and blocked with brooms, a dustpan, a meal cart with soiled meal trays, a trash can, box of gloves, and rolls of trash bags. These failures could place staff at risk for an unsafe, unsanitary, and uncomfortable environment. Findings included: During the initial tour of the kitchen on 10/29/2024 at 07:05 AM the following was observed: A sign on the wall reflected, Emergency Eyewash Keep Area Clear. Test All Emergency Equipment Weekly. An emergency eyewash station was mounted to the wall next to the hand washing sink…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-03 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 interventions the person-centered care plan to reflect the current condition for 1 (Residents # 1) of 5 residents reviewed for care plan interventions. The facility failed to update Resident # 1's care plan for diet interventions after her diet order was changed. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. The Findings included: Review of Resident # 1's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included Unspecified protein-calorie malnutrition (lack of proper nutrition or an inability to absorb nutrients from food) , hypertensive heart disease (heart conditions caused by high blood pressure), and vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain). Review of Resident # 1's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-03 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 provide food that accommodates residents allergies, intolerances, and preferences for 1 (Resident # 1) of 5 residents reviewed for food preferences. The staff did not accommodate Resident # 1's dietary preferences for a vegetarian diet. This failure could affect the residents that are provided daily meals by the facility, by placing them at risk for adverse effect from food, frustration, not enjoying meals, and weight loss. The Findings included: Review of Resident # 1's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Unspecified protein-calorie malnutrition (lack of proper nutrition or an inability to absorb nutrients from food) , hypertensive heart disease (heart conditions caused by high blood pressure), and vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain). 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-18 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Residents #1 and #2) of 6 reviewed for neglect and injuries of unknown origin. 1. The facility failed to report to SA within the required time frame of Resident #1's fall that resulted in a brain bleed and broken public…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-29 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor 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 observations, interviews, and record reviews, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 6 of 22 residents (Resident #s 1, 2, 3, 4, 5 &6) reviewed for resident rights. The facility failed to treat Resident #s1, 2, 3, 4, 5 & 6 with respect and dignity when they did not receive their lunch meal tray while the other residents seated with them in the dining room were already eating. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety. Findings: Review of Resident#1's undated face sheet revealed a [AGE] year-old female with admission date of 01/02/2024. diagnoses included hemiplegia and hemiparesis (hemiplegia refers to compete paralysis while hemiparesis refers to partial weakness on one side of the body that can affect the arm, leg and face) following cerebral infraction (occurs as a result 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-30 · 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 residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of fifteen residents (Resident # 4, Resident #4, Resident #73, and Resident #109 ) reviewed for quality of life. The facility failed to ensure Resident#4's, Resident #52's, Resident #73's, and Resident #109's fingernails were trimmed and cleaned. These failures could place residents at risk for poor hygiene, dignity issues and decreased quality of life. Findings included: 1. Record review of Resident #4's face sheet, dated 08/30/2023, reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis was characterized by one-sided weakness, but without complete paralysis), muscle…

    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 · D2023-08-30 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 promote and facilitate resident self-determination through support of resident choice for one (Resident #1) of eight residents reviewed for self-determination. CNA L denied Resident #1 the right to attend a group therapy activity. This failure placed Resident #1 at risk of mental anguish. Findings included: A record review of Resident #1's face sheet dated 8/30/2023 reflected a [AGE] year-old female originally admitted on [DATE] with diagnoses of multiple sclerosis (autoimmune disease), anxiety disorder, type 2 diabetes (uncontrolled blood sugar), dysthymic disorder (persistent depressive disorder), major depressive disorder (depression), unspecified dementia (cognitive decline), and cauda equina syndrome (spinal cord disease). A record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 12, which indicated mildly impaired cognition. This assessment reflected Resident #1 received hospice care. A 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-30 · 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, interviews and record reviews the facility failed to ensure each resident received adequate supervision and assistant devices to prevent accidents for 1 or 2 residents (Resident # 25) reviewed for accidents and hazards, in that: supervision. The facility failed to ensure staff properly transferred Resident #25 from her bed to wheelchair and suffered pain on her right arm between the elbow and the wrist. This failure could result in residents experiencing accidents, injuries, unrelieved pain, and diminished quality of life. Findings included: Record review of Resident #25's face sheet, dated 08/30/2023, revealed Resident #25 was a [AGE] year-old-female who was admitted to the facility on [DATE] with the diagnoses which included unspecified osteoarthritis, unspecified site (progressive, degenerative joint disease, the most common form of arthritis, especially in older persons), age-related osteoporosis without current pathological fracture (a disorder characterized by reduced bone mass),…

    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 · D2023-08-30 · tag F0711 — isolated
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    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 sign and date all orders for one (Resident #1) of eight residents reviewed for physician services. The facility's Physician failed to sign Resident #1's verbal order for hospice care. The facility failed to include in Resident #1's chart a signed order for hospice care. These failures placed Resident #1 at risk of receiving unconfirmed hospice services. Findings included: A record review of Resident #1's face sheet dated 8/30/2023 reflected a [AGE] year-old female readmitted on [DATE] with diagnoses of multiple sclerosis (autoimmune disease), anxiety disorder, type 2 diabetes (uncontrolled blood sugar), dysthymic disorder (persistent depressive disorder), major depressive disorder (depression), unspecified dementia (cognitive decline), and cauda equina syndrome (spinal cord disease). A record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 12, which indicated mildly impaired cognition. This assessment…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-30 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7 % based on 2 errors out of 32 opportunities, which involved 2 of 6 residents (Resident #15, and Resident #274) reviewed for medication errors. - MA N failed to apply medications as ordered to Resident #15 as by applying Lidocaine 4% patch to the resident's right knee instead of the back. - Facility failed to store and administer medications as ordered to Resident #274 by not ordering Linaclotide 290 mcg PO mg ER (medication for constipation). These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled pain. Findings included: Resident #15 Record review of Resident #15's Face Sheet dated 06/28/23 revealed, a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses which included: acute pain due to trauma and generalized anxiety…

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

    Pharmacy Service 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

$10,293 in federal fines across 1 penalty.

  • $10,293 — penalty dated 2024-07-18

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 CARADAY HEALTHCARE — 8 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 52.8+0.2 vs chain
Health inspection 2 of 53.0-1.0 vs chain
Staffing 2 of 51.6+0.4 vs chain
Quality measures 5 of 53.8+1.2 vs chain
The other 7 homes this chain runs (chain average 2.8★, per CMS)

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 / managerTypeRoleShareSince
CARADAY HEALTHCARE, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2020
CARA CAPITAL LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2020
CARADAY HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2020
DAYBACH INVESTMENTS, LPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2020
E&R CUNNINGHAM INVESTMENTS LPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2020
TALA INVESTMENTS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2020
YSMLC HOLDINGS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2020
CHOI, MARYANNIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2020
CHOI, ROBERTIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2020
O'DONOGHUE-STALLARD, MAIREIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2020
STALLARD, THOMASIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2020
WOOD, STEPHENIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2020
GRANITE ROUND ROCK, LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 01/01/2020
MOORE, GREGORYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2020
KROL, MICHAELIndividualADP OF THE SNFsince 01/01/2020
WALLACE, CHRISTYIndividualADP OF THE SNFsince 05/16/2022

CMS files one row per role, so the 18 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

8 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.

$10.2M
Net patient revenuemost recent cost report
-4.2%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 76%Medicare 5%Other / private 19%

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$236per resident / day
operating cost
$7,163per month
≈ monthly operating cost
$226per 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 675546. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-23, 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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