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The Lodge Of Saginaw Health And Wellness

848 W McLeroy Blvd, Saginaw, TX 76179 · For profit - Limited Liability company · 130 certified beds · (685) 900-1210 Medicare & Medicaid certified

Call the home — (685) 900-1210 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$15,944 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $15,944 in federal fines (most recent 2025-01-23)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (1/5)

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 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1029 N Saginaw Blvd, E3 · (214) 206-4706 · Call to confirm hours
Pharmacy
833 N Saginaw Blvd · (817) 306-7147 · Call to confirm hours
Grocery
548 Nathan St · (817) 470-9925 · Call to confirm hours
Park
Willow Vista Playground · Typically dawn to dusk
Place of worship

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 improved from 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
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 increased8.0%15.8%15.4%better
Long-stay residents who lose too much weight0.6%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.4%0.3%0.9%typical for the state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.8%0.8%2.0%typical for the state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%2.4%6.5%check this — see note marked star 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 injury4.8%3.3%3.3%worse
Long-stay residents whose ability to walk worsened8.2%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication27.4%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine81.1%98.0%95.3%worse
Long-stay residents with pressure ulcers2.7%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control13.1%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table4.7%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine68.7%88.0%79.4%worse
Short-stay residents rehospitalized after admission25.1%25.7%22.6%worse
Short-stay residents with an outpatient ER visit6.6%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days2.662.171.67worse
Long-stay outpatient ER visits per 1,000 resident days0.962.061.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

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

51.9% 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 159 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.9%U.S. median 51.5%
Got home and stayed home
13.0%U.S. median 10.7%
Went back to hospital
88.2%U.S. median 56.6%
Met the expected recovery
0.55U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.22hours / resident / day
Occupational therapy
0.15hours / resident / day
Speech therapy

Met the expected recovery: 88.2% 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 51 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 SNF51.9%CMS range 45.8–59.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.0%CMS range 9.9–17.110.7%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 discharge88.2%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 discharge80.4%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 discharge82.3%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 identified100.0%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 discharge93.5%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 stay4.6%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 worsened1.1%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 hospitalization5.9%CMS range 3.2–9.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.201.02Oct 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

0.28
RN hours/ resident / day
0.97
LPN hours/ resident / day
1.85
Aide hours/ resident / day
3.10
Total nurse hours/ resident / day
0.32
RN hoursweekends
55.3%
Total nursing turnover
56.3%
RN turnover

How full it usually is: this home is certified for 130 beds and averages 115.4 residents a day — about 89% occupied, or roughly 15 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 3.10 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 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 2.82 hrs/resident/day on weekends vs 3.22 on weekdays — 12% thinner on weekends. RN hours go from 0.27 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% 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

5
deficiencies at the latest standard inspection (2025-12-17)
7
at the previous standard inspection (2024-09-12)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2025-01-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 each resident received adequate supervision and assistance devices to prevent accidents for two of six residents (Resident #1 and Resident #2) reviewed for accidents. 1. On 12/31/24, CNA F and CNA G failed to safely transfer Resident #1 during the use of the mechanical lift, which resulted in the resident sustaining a scalp hematoma and T12 compression fracture. 2. On 12/18/24 the Van Driver failed to properly restrain Resident #2's wheelchair in the facility transportation van to prevent the wheelchair from tipping over on its side on the way to dialysis. The noncompliance was identified as PNC. The IJ began on 12/18/24 and ended on 01/20/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for severe injury or harm, decline in health, and decreased quality of life and death. Findings included: 1. Record review of Resident #1's MDS dated [DATE] reflected the…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · D2026-06-30 · tag F0842 — failed to keep accurate, complete medical records — isolated
    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 interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, maintain medical records that were complete and accurately documented for 1 of 11 residents (Resident #1) reviewed for clinical records. The facility failed to ensure facility staff documented bruising on Resident #1's Weekly Wound Progress Report during his admission from 04/04/26 - 06/23/26. This failure could place residents at risk for inaccurate assessments and monitoring.Findings include: Record review of Resident #1's face sheet, dated 06/30/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE] for rehabilitation after a significant cerebral infarction. Resident #1 had relevant diagnoses which included cerebral infarction (interruption of blood flow to the brain,) acute cystitis (inflammation of bladder,) atherosclerotic heart disease (accumulation of cellular waste in arteries,) and benign prostatic hyperplasia (non-cancerous enlargement 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 Assessment and Care Planning Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Ecited before2026-06-18 · 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 observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Residents #1and #2) of six residents reviewed for infection control. 1. The facility failed to ensure Wound Nurse J performed hand hygiene and changed her gloves during Resident #1 and #2's wound care on 06/18/26. 2. The facility failed to ensure CNA D performed hand hygiene and changed her gloves during Resident #1's incontinent care on 06/18/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings include: 1. Record review of Resident #1's face sheet dated 06/18/26 revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included pressure ulcer of sacral region, stage 4. Record review of Resident #1's MDS dated [DATE] revealed no BIMS…

    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 no plan of correction
  • Potential for harm · D2026-06-18 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    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 the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #3) of six residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #3's rooms were in a position that was accessible to the resident on 06/18/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record Review of Resident #3's Face Sheet, dated 06/18/2026, reflected a [AGE] year-old male admitted on [DATE]. The resident was diagnosed with muscle weakness and abnormalities of gait and mobility. Record Review of Resident #3's Comprehensive Care Plan, dated 04/23/26, revealed the resident has an ADL self-care performance deficit r/t decreased mobility, other lack of coordination with intervention to Encourage the resident to use…

    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 no plan of correction
  • Potential for harm · D2026-06-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    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 residents received treatment and care in accordance with professional standards of practice for one (Resident #2) of six residents reviewed for wound care. The facility failed to follow the facility's wound cleaning protocol for Resident #2's left above the knee amputation stump dressing change on 06/18/26. This failure put Resident #2 at risk of not receiving necessary treatment and a worsening of their wound.Findings included: Record review of Resident #2's face sheet dated 06/18/26 revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Acquired Absence of Left Leg Below Knee, Acquired Absence Of Right Leg Below Knee. Record review of Resident #2's MDS dated [DATE] revealed that the resident had a BIMS score of 15 (indicates no cognitive impairment). It revealed that the Resident has surgical wounds. Record Review of Resident #2's Physician Order dated 06/08/26 revealed Left leg/AKA stump: Cleanse…

    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 no plan of correction
  • Potential for harm · Dcited before2026-06-18 · 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 Tag: F689 /4027S/S= D Surveyor Name(s): [NAME] NnadiImmediate Supervisor: Verlair AsheBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 2 of 6 residents (Resident #3 and #6) reviewed for accident prevention. The facility failed to ensure Resident #3's fall mat was placed alongside his bed while she was lying in the bed on 06/18/26. 2. The facility failed to ensure Resident #6's bed was in a low position for fall prevention per the care plan while he was lying in bed on 06/18/26. This failure could prevent the residents from having an environment that was free from hazards.Findings include: Record Review of Resident #3's Face Sheet, dated 06/18/2026, reflected a [AGE] year-old male admitted on [DATE]. The resident was diagnosed with muscle weakness and abnormalities of gait and mobility. Record Review of Resident #3's Comprehensive Care Plan, dated 04/23/26, revealed the resident has an ADL…

    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 no plan of correction
  • Potential for harm · D2026-06-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    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 observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #4 and Resident #5) of six residents reviewed for respiratory care. 1. The facility failed to ensure Resident #4 's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly when not in use on 06/18/26. 2. The facility failed to ensure Resident #5 's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) and BiPAP mask was stored properly when not in use on 06/18/26. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings include: 1. Record review of Resident #4's Face Sheet, dated 06/18/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. The 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Ecited before2025-12-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 Residents (Resident #63 and Resident #5) of 23 residents reviewed for bowel and bladder incontinence.1. The facility failed to ensure Resident #63 was not left in soiled briefs, or being double briefed.2. The facility failed to ensure Resident #5 had physician's order for an indwelling catheter (device used to drain urine from bladder). This failure could place residents at risk of skin breakdown, infections and improper treatment. Findings included: 1. Record review of Resident #63's quarterly MDS, dated [DATE], reflected Resident #63 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included heart failure, dementia, and cognitive communication deficit. The resident had severe cognitive impairment with a BIMS score of 2.…

    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 · Ecited before2025-12-17 · 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 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 2 of 32 residents (Residents #13 and #98) reviewed for pharmacy services. The facility failed to administer the morning medications on time resulting in Residents #13's hydrocodone scheduled for 2:00 PM not being administered and Resident #98's hydralazine not being administered at 2:00 PM on 12/15/25. This failure could cause residents to develop changes in their medical conditions. Findings included:Record review of Resident #13's quarterly MDS, dated [DATE], reflected Resident #13 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic pain, rotator cuff pain, and Alzheimer's Disease. Her BIMS score was 11, indicating she had moderate cognitive impairment. Her Functional Ability 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-17 · 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 ensure food, subject to spoilage and removed from its original container, was kept sealed, labeled, and dated in 1 of 1 kitchen. The facility failed to ensure various foods stored in the kitchen freezer inside the walk-through fridge were sealed, dated and labeled and remove items opened past 7-day time frame. This failure could place all residents at risk for food contamination and food borne illness. Findings included: Observation and interview of the walk-through fridge on 12/15/25 at 9:00 AM with the Dietary Manger revealed a container of red sauce, corn, gravy, and green beans were not labeled identifying the contents and did not have a disposal date. The fridge also had open, exposed diced ham, and sliced turkey in their original packaging that was not sealed and open to air nor did it have a disposal date. The fridge also had link sausage in its original packaging that was open to air and did not have a disposal date. Observation of the freezer inside the walk-through fridge two clear bags 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
  • Potential for harm · E2025-12-17 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide in-service training that was sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year and included dementia management training, resident abuse prevention training and care of the cognitively impaired for 2 (CNA G and CNA H) of 5 CNAs reviewed for annual training. The facility failed to provide CNA G and CNA H with 12 hours per year of annual training. This failure could place residents at risk of being cared for by untrained staff.Findings included:Review of CNA G's personnel record revealed a hired date of 10/24/23. The annual training in-service provided by the facility did not include evidence of 12 hours of annual training. Review of CNA H's personnel record revealed a hired date of 02/28/23. The annual training in-service provided by the facility did not include evidence of 12 hours of annual training. Interview on 12/17/25 at 4:27 PM with ADON G who stated inservices with the CNA's were provided by ADON's and DON collectively. ADON G said she was aware all…

    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
Show the remaining 18 citations
  • Potential for harm · D2025-12-17 · 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 observation, record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 5 residents (Resident #54) whose drug regimens were reviewed. The facility failed to clarify Resident #54's orders for KCL (potassium chloride, which is used to treat and prevent low blood potassium levels) and Clonidine (a medication used to treat hypertension) when the facility's Pharmacy Consultant made the recommendation for the change on 09/29/25 when the order was to give the medications by mouth. This failure could place residents receiving medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition. Findings included: Record review of Resident #54's Quarterly MDS Assessment, dated 11/05/25, reflected he was a [AGE] year-old male who was readmitted to the facility on [DATE]. He had a BIMS score of 10 which indicated moderate cognitive impairment. His active diagnoses…

    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 · E2025-12-04 · tag F0552 — pattern
    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 observation, interview and record review the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment, including: The right to be fully informed in language that he or she could understand of his or her total health status, including but not limited to, his or her medical condition. for 2 of 12 residents (Residents #1 and #2) reviewed for resident rights. The facility failed to ensure the staff was adequately able to communicate with Residents #1 and #2 in their primary language, Spanish, for their care and service needs. This failure place residents at risk of their needs not being met, which could decrease their health and psychosocial well-being.Findings included: A)Record review of Resident #1's admission assessment dated [DATE] revealed a [AGE] year old Mexican American female with a preferred language of Spanish who admitted [DATE]. She had a BIMS score of 11 (Moderate impairment) and for daily preferences it was very important to make…

    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 · E2025-12-04 · tag F0656 — failed to write and follow a full care plan — pattern
    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 observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 12 residents (Residents #1 and #2) reviewed for care plans.The facility failed to ensure their IDT created a communication care plans for their Spanish speaking Residents #1 and #2.This failure could place residents at risk of their needs not being met, which could decrease their health and psychosocial well-being.Findings included: A)Record review of Resident #1's admission assessment dated [DATE] revealed a [AGE] year old Mexican American female with a preferred language of Spanish who admitted [DATE]. She had a BIMS score of 11 (Moderate impairment) and for daily preferences it was very important to make decision about choosing clothes 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-04 · tag F0550 — failed to protect resident dignity and rights — isolated
    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 record review and interviews, the facility failed to ensure the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility and protect and promote the rights of each resident for 1 of 9 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #3 did not remain covered in a substance, which appeared to be dried vomit and other detritus, for an extended period. This failure could place residents at risk of psychosocial harm. Findings included:Record review of Resident #3's admission sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included malignant neoplasm of unspecified part of unspecified bronchus or lung (a type of cancer that originates in the lungs, but the exact location within the lungs is unknown); methicillin susceptible staphylococcus aureus infection (a common bacterial infection caused 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-06 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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 residents had the right to a safe, clean, comfortable, and homelike environment, which included but were not limited to receiving treatment and supports for daily living for one (Resident #1) of six residents reviewed for environment. The facility failed to ensure Resident #1's personal photographs and décor were moved with her into the room she had to temporarily move into on 09/26/24, due to a Covid-19 (a severe acute respiratory syndrome) outbreak. This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment. Findings included: Review of Resident #1's Face Sheet, dated 10/06/24, reflected she was an [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including cerebral infarction (also known as an ischemic stroke; occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia 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 before2024-09-12 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to 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 2 (1 nurses medication cart for 400 hall and medication aide cart for 400 and 200 halls) of 3 carts and 1 refrigerator in the medication room reviewed for pharmacy services. The facility failed to ensure expired intravenous medications, 3 bottles ampicillin-sulbactam 3 gm/100 ml with expiration dates of 09/03/24, 8 bottles ampicillin-sulbactam 3gm/100mls with expiration dates of 09/07/24, 3 bottles Piperacillin /tazobactam with expiration dates of 09/06/24 and 4 bottles meropenem 1 gm/100mls with expiration dates of 08/18/24, in the Medication Room refrigerator and 11 vials of hydroxyzine with expiration dates of July 2024 in the nurse and 7 sachets of pantoprazole sodium delayed release on the medication aide medication carts with expiration dates of July 2024 were removed and destroyed. The failure placed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-12 · 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 ensure food, subject to spoilage and removed from its original container, was kept sealed, labeled, and dated in the facility's only kitchen. 1. The facility failed to ensure food items stored in the refrigerator were properly labeled with the contents after being removed from the original packages and dated to reflect when the food items were opened. 2. The facility failed to ensure food items stored in the refrigerator were properly discarded based on expiration date. 3. The facility failed to store ground meat and pot roast were wrapped in plastic wrap away from the original packaging with liquids flowing onto the tray with other items and had turned to a dark/grey color. These failures could place all residents at risk for food contamination and food borne illness. Findings included: Observation of the refrigerator on 09/10/24 beginning at 9:34 AM revealed the following: - observation of bucket of green beans with no label or date; - a tray holding a box of chicken, ground meat, pot roast, and a large…

    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 before2024-09-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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 resident had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #30) of six residents reviewed for resident rights. The facility failed to ensure Resident #30's wheelchair was free of debris. This failure could place residents at risk of not having a safe, clean, comfortable, and homelike environment. Findings included: Record review of Resident #30's admission Record dated 09/12/24 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease without dyskinesia (neurodegenerative disease that affects both motor and nonmotor systems of the body), bilateral primary osteoarthritis of hip (inflammation and injury to a joint causing a breakdown of cartilage tissue), difficulty in walking, muscle weakness, lack of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing based on the comprehensive assessment for 1 of 4 residents (Resident #22) reviewed for pressure ulcers. The facility failed to ensure the DTI on Resident #22's right and left buttocks across the sacrum was covered with a dressing. This failure could place residents at risk of pain and lead to systemic infections causing harm for residents. Findings included: Review of Resident #22's face sheet dated 09/12/24 reflected the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #22 had diagnoses which included diabetes (high blood sugar) and other specified non-inflammatory disorders of vulva and perineum. Review of Resident #22's quarterly MDS assessment dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-12 · 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 observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible to prevent accidents for 1 of 1 resident (Resident#87) reviewed for hazards. The facility failed to ensure LVN H discarded sharps in the sharp containers. This failure placed residents at risk of being exposed to contaminated sharps and possible bloodborne pathogens. Findings included: Record review of Resident #87's face sheet, dated 09/12/24, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #87's diagnoses included major depressive disorders (common mental disorder that causes a persistent depressed mood and loss of interest in activities for long periods of time) and gastrostomy status (a surgical opening into the stomach for nutritional support). Review of Resident #87's quarterly MDS assessment, dated 06/01/24, revealed the resident had intact cognition with a BIMS score…

    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 · Dcited before2024-09-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #75) of four residents reviewed for quality of care. The facility failed to ensure Resident #75's catheter bag was not on the floor. This deficient practice could place residents at risk for UTIs and other infections. Findings included: Record review of Resident #75's face sheet, dated 09/12/24, reflected an admission date of 05/02/23, and re-admission date of 06/20/24. Resident #75 had diagnosis which included encounter for fitting and adjustment of urinary device (catheter), symptoms and signs concerning food and fluid intake, chronic kidney disease stage 3 (mild to moderate kidney damage), hypertensive heart (complications of high blood pressure) and chronic kidney disease (gradual loss of kidney function) with heart failure. Record review of Resident #75's quarterly MDS assessment, dated 06/24/24, reflected 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-12 · 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 observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs for 1 of 3 residents (Resident #87) reviewed for pharmacy services. 1. The facility failed to ensure LVN H administered Resident #87's Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg 1 capsule via gastrostomy tube, in the morning related to mood on 09/11/24 at 7:51 AM. 2. The facility failed to ensure LVN H checked the residual (the volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding) before administering medication through gastrostomy on Resident #87. These failures could place residents at risk of medical complications. Findings included: Record review of Resident #87's face sheet, dated 09/12/24, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #87's diagnoses…

    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 · D2024-05-31 · tag F0620 — isolated
    Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
    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 implement an admissions policy that did not request or require residents to waive potential facility liability for loss of personal property for 1 of 1 policy reviewed. The facility failed to not request or require residents or potential residents to waive potential facility liability for losses of personal property. This failure could place residents at risk of misappropriation of their personal property. Findings included: Review of Resident #1's MDS dated [DATE] revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hydronephrosis (excess fluid in a kidney due to backup of urine), diabetes, dementia, depression, and anxiety. The resident had a BIMS of 15, cognition intact. Review of Resident #1's Grievance/Concern Report dated [DATE] completed by the Social Worker reflected the following: .Concern/Details Resident reports that she is missing $800.00 and all her credit cards from her wallet. She…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-31 · tag F0880 — failed to prevent and control infections — isolated
    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 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 one (Resident #4) of 1 resident reviewed for infection control during wound care. LVN C failed to change gloves and perform hand hygiene while providing wound care to Resident #4. These failures could place residents at risk of infection, slow wound healing, and or a decline in health. Findings included: Review of Resident #4's entry MDS assessment dated [DATE] revealed Resident #4 was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis which included non-Hodgkin's lymphoma (a type of cancer that begins in the lymphatic system). Resident #4 had a BIMS score of 13 which indicated Resident #4's cognition was intact. The MDS also revealed Resident #4 required surgical wound care. Review of Resident #4's wound…

    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 · E2023-09-13 · tag F0694 — pattern
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the residents goals and preferences for one (Resident #1) of three residents reviewed for intravenous medication administration. The facility failed to ensure Resident #1 received the proper care for her peripherally inserted central catheter (PICC) line when: 1. Multiple facility staff failed to discontinue the PICC line when ordered by her physician from 8/22/2023 through 8/26/23, and 2. Multiple facility staff failed to ensure the dressing to her PICC line was changed weekly as ordered and stated in the facility policy. These failures placed the residents with parenteral/IV fluids and lines at risk for infection. Findings included: Record review of Resident #1's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses…

    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 · E2023-08-17 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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 provide at least three meals daily at regular times comparable to normal mealtimes in the community or in accordance with resident needs and plan of care; and ensure that there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, for 2 of 2 meals (breakfast) observed. The facility failed to serve the 08/16/23 and 08/17/23 breakfast meals on time according to the schedule. This failure could place all residents who consume food by mouth at risk for decreased meal satisfaction, decreased intake, loss of appetite, avoidable weight loss, side effects from medications given without food, and diminished quality of life. Findings included: Record review of the facility's Mealtimes revealed the following: Breakfast- 7:30 AM, Lunch- 12:00 PM, Dinner- 5:30 PM. Observation on 08/15/23 at 5:24 PM revealed Halls 100, 200, 300, and 400 dinner trays were being pushed to the halls and approximately 30 residents in the dining room…

    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 before2023-08-17 · 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 food panty items were properly stored in plastic bags, labeled, and dated in accordance with professional standards. These failures could place all residents, who receive food from the kitchen, at risk for food contamination and food-borne illness. Findings included: An observation on 08/15/23 at 9:20 AM revealed the following: In dry goods pantry: - Coconut flavoring opened, used, and without an open date, - Cereal opened in sealed clear bag without an open date, - Package of spaghetti opened in sealed clear bag without an open date, - Individual box of raisins opened, without an open date and not in a sealed clear bag or container, - Cookies opened in sealed clear plastic bag without an open date, - Corn chips opened in a sealed clear plastic bag, without an open date, and - Grape jelly opened, used and not refrigerated as per the manufacturer'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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-17 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and assure only authorized personnel to have access to the keys for 2 (Resident #36 and Resident #137) of 5 residents reviewed for pharmacy services, in that: The facility failed to ensure Resident #36 prescribed eye drops and Resident #137's eye drops, magnesium tablets, Thera cream, and vitamins were stored in a secured place. This failure could place all residents on the 300 and 400 Halls at risk of drug diversion or misuse of medications. Findings included: 1. Record review of Resident #36's face sheet, dated 08/17/23, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Cerebral infarction (lack of adequate blood supply to brain due to issues with arteries that supply it), multiple fractures of ribs, sacral, vertebra and sacrococcygeal area and other age-related cataract (cloudiness in the lens of the eye). Record review of Resident #36'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.

    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

$15,944 in federal fines across 1 penalty.

  • $15,944 — penalty dated 2025-01-23

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 ML HEALTHCARE — 6 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 52.3+0.7 vs chain
Health inspection 3 of 52.3+0.7 vs chain
Staffing 1 of 51.2-0.2 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 5 homes this chain runs (chain average 2.3★, 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
ML LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/15/2022
LANGSDALE, TROYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF50%since 07/15/2022
MILLER, LAURAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF50%since 04/13/2021
TEXAS OPPORTUNITY FUND SNF INVESTMENT LPOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 12/09/2020
ML HEALTHCARE MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/15/2022
SCIACCA, CHRISTOPHERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/15/2022
MOON, JAMIEIndividualADP OF THE SNFsince 07/15/2022

CMS files one row per role, so the 15 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$7.8M
Net patient revenuemost recent cost report
-7.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 54%Medicare 19%Other / private 27%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$312per resident / day
operating cost
$9,480per month
≈ monthly operating cost
$291per 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 745017. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-17, 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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