Avir at San Angelo
5455 Knickerbocker Rd, San Angelo, TX 76904 · For profit - Corporation · 125 certified beds · (325) 944-1660 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $91,080 in federal fines (most recent 2025-03-06)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 30.5% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.9% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.4% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.4% | 2.4% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.7% | 0.0% | 0.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 8.6% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 27.8% | 14.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 15.2% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.8% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.5% | 3.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 22.7% | 13.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.2% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.2% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 97.9% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.2% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 19.8% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.92 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.15 | 2.06 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
53.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 48.3% 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 60 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 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 53.5%CMS range 39.8–65.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 14.9%CMS range 10.7–20.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 48.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 63.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 46.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.3% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.5%CMS range 3.3–12.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 125 beds and averages 84.5 residents a day — about 68% occupied, or roughly 40 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.99 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.15 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.88 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 2.73 hrs/resident/day on weekends vs 3.10 on weekdays — 12% thinner on weekends. RN hours go from 0.16 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
34 citations, most serious first. The 14 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · Kcited before2023-12-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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, interview, and record review, the facility failed to maintain an environment that was free from accidents and hazards for 31 (All resident on 100 Hall) of which 5 of 31 (Resident #81,82, 20, 40, and 77) had cognitive decline that could still access their sinks, of 90 residents. -Temperature readings for the public restroom on the 100 hall were 128 degrees Fahrenheit. -The temperature reading in the restroom to Resident room [ROOM NUMBER] on the 100 hall was 128 degrees Fahrenheit. -5 residents on the 100 hall had cognitive decline and could access their sinks. An Immediate Jeopardy to residents' health or safety was identified on 12/21/23. The Immediate Jeopardy template was provided to Administrator on 12/21/23 at 7:23PM. While the Immediate Jeopardy was removed on 12/22/23 at 7:38PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a severity level of a pattern as the facility began lowering water heater…
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.
- Actual harm · H2025-03-06 · tag F0685 — patternAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assist the residents in making appointments to ensure residents receive proper treatment and assistive devices to maintain hearing abilities for one of two residents (Resident #45) reviewed for hearing devices. The facility failed to make an appointment for an audiologist for Resident #45 after the Responsible Party requested one on 8/20/24. This failure could place residents at risk of decreased communication ability, quality of life, and/or social isolation. The findings included: Review of Resident #45's admission Record, dated 2/29/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including hearing loss. Review of Resident #45's Quarterly MDS Assessment, dated 11/29/24, revealed: She had a BIMS score of 5 of 15 (indicating severe cognitive impairment); She had minimal difficulty hearing (Difficulty in some environments e.g. when person speaks softly or setting is noisy); and She wore hearing…
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.
- Actual harm · H2025-03-06 · tag F0745 — failed to provide medically-related social services — patternProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 assist the residents in making appointments to ensure residents receive proper treatment and assistive devices to maintain hearing abilities for one of two residents (Resident #45) reviewed for hearing devices. The facility failed to make an appointment for an audiologist for Resident #45 after the Responsible Party requested one on 8/20/24. This failure could place residents at risk of decreased communication ability, quality of life, and/or social isolation. The findings included: Review of Resident #45's admission Record, dated 2/29/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including hearing loss. Review of Resident #45's Quarterly MDS Assessment, dated 11/29/24, revealed: She had a BIMS score of 5 of 15 (indicating severe cognitive impairment); She had minimal difficulty hearing (Difficulty in some environments e.g. when person speaks softly or setting is noisy); and She wore hearing…
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.
- Actual harm · H2023-09-13 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 received the correct prescribed seizure medication Carbamazepine, which resulted in the resident having a seizure and was transferred to the hospital. Resident #1 missed 6 doses of the medication from 08/11/23 through 08/13/23. This failure resulted in actual harm to Resident #1 on 08/14/23. The noncompliance was determined to be past noncompliance (PNC). The noncompliance began on 08/11/23 and ended on 08/14/23. The facility had implemented the actions that corrected the noncompliance before the surveyor's entrance to the facility on [DATE]. This failure could place residents at risk of complications from deterioration in health, and hospitalizations. Findings include: Record review of Resident #1's face sheet revealed he was a [AGE] year-old male, who was admitted 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.
- Potential for harm · E2026-05-07 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #21) of three residents reviewed for PASRR Level 1 screenings. The facility failed to refer Resident #21 to the State-designated authority for a PASRR Level II review when she was admitted with a diagnosis of schizophrenia and a PASRR Level 1 positive for mental illness. This failure could place residents with mental illness at risk of not receiving a PASRR Evaluation, individualized care, or special services to meet their needsFindings include: A record review of Resident #21's face sheet, dated 5/7/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included depression (mental health condition that causes a persistent low mood and loss of interest in activities), anxiety (cognitive decline caused by vessel damage that features panic like episodes), schizophrenia (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #11) and 9 of 47 sharps containers reviewed for accidents and hazards. The facility failed to ensure bed alarm was plugged in while Resident #11 was in bed as indicated on his current comprehensive care plan and current physician's orders. The facility failed to ensure sharps containers were replaced when full in 9 rooms (Rooms: 105, 106, 108, 109, 111, 113, 207, 210, and 401). The failures could place residents at risk for injury.The findings include: 1. Resident #11 A record review of Resident #11's face sheet, dated 05/7/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #11 had diagnoses which included unspecified dementia (A group of thinking and social symptoms which interferes with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly stored, labeled, and dated.2. The facility failed to ensure prepared food was discarded after 72 hours (3 days) per facility policy. 3. The facility failed to prevent cross-contamination of food items when pureeing food.4. The facility failed to ensure personal food items were not stored in 1 of 2 of the kitchen refrigerators. 5. The facility failed to ensure the dietary staff wore beard covers while in the kitchen.These failures could place residents who received prepared meals from the kitchen at risk of food borne illness and cross-contamination. The findings included:During the initial tour of the kitchen on 05/05/2026 at 9:00 AM, the following was observed: The DM did not have a beard cover over his beard.Milk Refrigerator:A glass bottle of tea was opened.A container labeled ketchup…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-07 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations, interviews and record review the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters reviewed for environment. The facility failed to ensure garbage was placed in a covered dumpster.These failure could affect residents by placing them at risk of illnesses, or be provided an unsafe, unsanitary, and uncomfortable environment.Findings include:Observation on 05/05/2026 at 10:15 AM of garbage area outside, revealed a large rectangle roll off dumpster that did not have a lid and the bags of trash were piled higher than the rim.During an interview on 05/07/2026 at 4:12 PM with the Administrator, he said they do not have a garbage disposal policy. He said he was aware of the roll off dumpster and he had instructed staff not to use it. He said he emailed city offices to get it hauled off. The administrator said that using it for regular daily trash could cause pests and trash could be scattered by the wind and/or pests.
- Potential for harm · Dcited before2026-05-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #23, and Resident #42) of 12 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #23 for ADL dependence and means to address psychosocial needsThe facility failed to develop a comprehensive person-centered care plan regarding hospice services for Resident #42.This deficient practice could place residents in the facility at risk of not receiving the necessary care or services. Findings include:Findings: Resident #23Record review of Resident #23's face sheet, dated 05/06/2026, had revealed admission to the facility on 2/17/2026. Resident #23 was a [AGE] year-old…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-07 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 2 residents (Resident #8) reviewed for trauma-informed care. The facility failed to ensure Resident #8 had a trauma screening completed upon admission to the facility that identified possible triggers when Resident #8 had a history of trauma. This failure could place residents at an increased risk for psychological distress due to re-traumatization.The findings included: A record review of the face sheet, dated 05/07/26, reflected Resident #8 was a [AGE] year-old female who initially admitted to the facility on [DATE] with a diagnosis of PTSD (mental health condition that develops following a traumatic event characterized 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.
- Potential for harm · D2026-05-07 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 observations, interviews and record review the facility failed to ensure a medication error rate of less than 5%, and the medication error rate was 7.14% with 2 errors in 28 opportunities involving 1 staff (LVN D) and 1 resident (Resident #3) reviewed for medication pass. LVN D did not fully administer the crushed medications to Resident #3 via PEG tube. (Percutaneous Endoscopic Gastrostomy, a medical procedure used to insert a feeding tube directly into the stomach through the abdominal wall.) This failure could place residents at risk of not receiving their medications as prescribed according to physician's orders and facility policy and procedures. Findings include: Record review of Resident #3's admission record dated 05/07/2026 indicated she was admitted to the facility on [DATE] with diagnoses of stroke and essential hypertension (high blood pressure). She was [AGE] years of age. Record review of Resident 3's physician's orders dated 05/07/2026 indicated in part: Lisinopril Oral Tablet 40 MG Give…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-07 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 (hall 2 cart) observed for medication storage and security. MA C failed to ensure her medication cart was secured when it was left unattended on 05/05/2026. These failures could place clients at risk for drug diversion or accidental ingestion. Findings included: Observation and interview on 05/05/2026 at 9:14 AM the hall 2 medication cart was seen unlocked and unsupervised. The DON was made aware of the cart unlocked. The cart was inspected with the DON present. On the top drawer were several over the counter medication bottles. Inside the other drawers were some blister packs that contained several prescribed medications. The DON said that it was expected for the staff to lock the medication carts whenever they left the carts unattended. Interview on 05/05/2026 at 9:22 AM MA C said the hall 2 medication cart was the cart she had used today 05/05/2026. The MA said she was sure she had locked the cart when she had stepped away. MA C said she was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-07 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #37) of 3 residents reviewed for infection control. CNA A failed to change her gloves after they became contaminated while assisting Resident #37 with incontinent care. This failure could place residents' risk for cross contamination and the spread of infection. Finding include: Record review of Resident #37's admission record dated 05/05/2026 indicated he was admitted to the facility on [DATE] with diagnoses of dementia and unsteadiness on feet. He was [AGE] years of age. Record review of Resident #37's MDS dated [DATE] indicated in part: Urinary continence = Always incontinent. Bowel continence = Always incontinent. Record review of Resident #37's care plan revised on 05/07/2026 indicated in part: The resident has…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 interview and record reviews, the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 4 residents reviewed for pressure ulcers. The facility failed to obtain treatment orders for wound care upon admission for Resident #1. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain.Findings included:Record review of Resident #1's face sheet undated revealed [AGE] year-old male admitted [DATE] from another nursing facility. Diagnoses included encounter for orthopedic aftercare following surgical amputation (the need for aftercare and follow up of a patient who has undergone surgical amputation), type 2 diabetes mellitus (metabolic condition where the body develops insulin resistance, causing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · Ecited before2025-11-19 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 (Residents #1, #2, and #3) residents reviewed for comprehensive care plans.The facility failed to have a care plan for Resident #1's dialysis, diabetic care, glaucoma, seizures, mental health needs, wound care, blood pressure monitoring, ADL assistance, and vaccine status. The facility failed to have a care plan for Resident #2's mental health and behavioral issues, pain, high blood pressure, hospice services, ADL needs, communication, cognitive status, nutritional status, risk to skin impairment, incontinence, or vaccination status. The facility failed to have a care plan for Resident #3's code status, mental and behavioral needs, kidney disease, pain, dietary or fluid restrictions, low thyroid,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (Resident #2 and Resident # 3) reviewed for accident and hazards: The facility failed to implement care planned anti-slip strips on the floor in front of Resident # 2's recliner. The facility failed to implement care planned [NAME] sheet (anti-slip device) in Resident #3's wheelchair. This failure could place residents at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues because of accident hazards. Findings included: Review of Resident #2's admission Record, dated 2/3/25, revealed she was an [AGE] year-old female admitted to the facility with diagnoses including dementia, diabetes (a disorder where the body does not use blood sugar properly), and history of falls. Review of Resident #2'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.
- Potential for harm · F2025-03-06 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for physical environment. The facility failed to ensure one of six stove top burners ignited automatically. This failure could place residents at risk of foodborne illnesses and potential for injury to residents and staff. Findings included: During an observation and interview on 02/18/25 at 10:02 AM, the stove in the kitchen was inspected. One of the six burners was noted to not turn on when the knob was turned to the on position by [NAME] E. [NAME] E said the burner had not worked for a while and was not sure what was wrong with it or if it was clogged. The DM attempted to try and light it up manually, but it would not light up. During the time the DM turned the knob you could hear and smell the gas coming out of the pilot, but it would not light the burner. The burner appeared to have a buildup of grease on some sort of gunk on it. The DM said they would try to wash the burner to see if it unclogged it.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-06 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 (Residents #14 and #28 and #288) of 4 residents reviewed for infection control in that: CNA F failed to wash her hands and change her gloves after they became contaminated during incontinent care while assisting Resident #14. CNA D used double gloves when she performed incontinent care for Resident #28. RN K failed to wash her hands and change her gloves after they became contaminated during wound care performed on Resident #288. These failures could place resident's risk for cross contamination and the spread of infection. Finding include: RESIDENT 14 Record review of Resident #14's admission record dated 02/20/25 indicated he was admitted to the facility on [DATE] with diagnoses of dementia. He was [AGE] years of age. Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
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 the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed for 1 0f 4 residents (Resident #1) reviewed for resident rights. Transfer and the reason for the transfer before the roommate was changed. Based on interview and record review the facility failed to ensure residents legal guardian had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 1 of 1 resident (Resident #60) reviewed for resident rights. The facility failed to ensure the Social Worker told Resident #1's representative the reason for his room change following an incident with his roommate on 9/17/24. This failure could place resident's roommate at risk for not being…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 interview, and record review the facility failed to ensure Residents were free from abuse a 1 of 6 residents (Resident #1) reviewed for abuse. 1. The facility to protect Resident #1 from Resident #2 pouring water on Resident #1 when he annoyed him. The deficient practices could affect any resident and contribute to further abuse or neglect. Findings included: Record review of Resident #1's Face Sheet (admission Record) dated 10/03/24 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's medical history included muscle wasting, dementia, schizoaffective disorder (a mental health condition that includes schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms such as depression and mania), anxiety disorder, and major depressive disorder (depressed mood all or most of the time). Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated Resident #1 could usually be understood and could usually understand others. The MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 all alleged violations involving abuse are reported immediately to the Administrator of the facility for 1 of 6 residents (Resident #1) reviewed for abuse. 1. CNA B failed to immediately report her suspicions of abuse when she found Resident #1 Wet . The deficient practices could affect any resident and contribute to further abuse or neglect. Findings included: Record review of Resident #1's Face Sheet (admission Record) dated 10/03/24 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's medical history included muscle wasting, dementia, schizoaffective disorder (a mental health condition that includes schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms such as depression and mania), anxiety disorder, and major depressive disorder (depressed mood all or most of the time). Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated Resident #1 could…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-12-22 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to review the work of each Certified Nurse Assistant (CNA) at least once every 12 months, for 4 (CNA A, CNA B, CNA C and CNA D) of 4 CNAs reviewed for annual competency evaluations (there were only 4 CNAs that had worked at the facility longer than a year). This deficient practice could affect 90 residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs. Findings include: Record Review of Personnel Files revealed the following: - Employee record for CNA A revealed a hire date of 04/02/2021, with no evidence of a competency evaluation in the past 12 months. There was no record of a previous competency evaluation. - Employee record for CNA B revealed a hire date of 04/01/2019, with no evidence of a competency evaluation in the past 12 months. The last competency evaluation was completed on 04/25/2022. - Employee record for CNA C revealed a hire date of 04/01/2019, with no evidence of a competency evaluation in the past 12 months. The last competency evaluation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-12-22 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to develop and implement an infection prevention and control program to include antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 facility reviewed for antibiotic stewardship. The facility failed to utilize an antibiotic tracking log for the months of September 2023 through December 2023. This failure could place residents at risk for inappropriate antibiotic use. The findings include: In a record review of facility's antibiotic tracking log , the last month the tracking and trending on antibiotic usage was completed in August of 2023. The tracking logs for September 2023, October 2023, November2023, and December 2023 were not completed. In an interview on 12/21/23 at 11:59 AM, the DON provided a Policy for Infection Control and said the facility used the Policy and Procedure but it does not meet the standards of tracking and antibiotic stewardship. She said she was new in the DON position and has not received training for infection prevention and tracking. In an interview on 12/21/23 at 5:15 PM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-22 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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
Based on observation, interview and record review, the facility failed to promote care in a manner that maintained and enhanced each resident's right to a dignified existence dignity and respect for 2 (Resident #'s 54 and 75) of 22 residents reviewed for dignity. The facility failed to ensure Resident #54 was properly dressed and, in his wheelchair, when assisted to and from the shower room to take a shower. The facility failed to ensure that resident #75 was provided privacy when her finger stick blood sugar was taken in the dining room before her lunch. These failures placed residents at risk of not being provided care and services in a respectful and dignified manner that could result in a loss of the resident's self-esteem and quality of life. Findings included: Review of Resident #54's face sheet dated 12/19/23, revealed he was an 84- year-old male admitted to the facility on 05//06/21. Review of Resident #54's quarterly MDS assessment, dated 11/10/23, revealed he had clear speech, was understood by others, and was able to understand others. Resident #54's cognition was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-22 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide both a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (Form CMS-10055) and a Notice of Medicare Non-coverage (Form CMS-10123 general notice) for 2 of 3 residents (Residents #3 and #83) reviewed for Medicare Beneficiary Protection Notification when discharged from Medicare Part A Services with benefit days remaining. 1. The facility failed to ensure Resident #3's representative was given a NOMNC (Form CMS-10123 general notice) and a SNF ABN (Form CMS-10055) when he was discharged from skilled services. 2. The facility failed to ensure Resident #83's representatiive was given a NOMNC form and a SNF ABN form when she was discharged from skilled services. These failures could place residents and their representatives at risk of not being fully informed about services covered by Medicare. The findings included: 1. Resident #3 Review of Resident #3's admission Record, dated 12/22/23, revealed a [AGE] year-old male who was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-22 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a summary of the baseline care plan was provided to the resident and their representative for 2 of 7 residents (Resident #s 89 and 349) reviewed for baseline care plans following admission into the facility for skilled nursing care services, in that: 1. Resident #89's had baseline care plans dated 11/17/23 and 11/27/23, and a summary had not been provided to her or her representative. 2. Resident #349's baseline care plan was dated 12/14/23 and a summary had not been provided to him. This failure placed the residents at risk for not receiving information regarding the care and services to be provided to meet their needs and to promote their physical and mental health and well-being within their new living environment. The findings included: 1. Resident #89 Review of Resident #89's admission Record, dated 12/22/23, revealed an [AGE] year-old female initially admitted to the facility on [DATE]. The form documented the resident was hospitalized on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-22 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 that residents who were unable to conduct activities of daily living received the necessary services to maintain good personal hygiene for 3 of 26 residents (Resident's #3, #34, #54), reviewed for activities of daily living. -The facility failed to provide nail care for Resident #3. -The facility failed to provide oral care for Resident #3, #34 and #54. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, skin breakdown, dental pain and cavities, and a decreased quality of life. Findings included: Resident #3 Record review of Resident #3's MDS r evealed he was a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses: Diabetes (high level of sugar in the blood), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), hemiplegia (muscle weakness or partial paralysis on one side of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 4 residents (Resident #3 and Resident #88) reviewed for respiratory care. A. Resident #3's and #88's nebulizer mask and tubing were not kept in a plastic bag when not in use. B. Resident #3's oxygen cannula and tubing were not kept in a plastic bag when not in use. This failure could place residents requiring oxygen at risk for respiratory infections due to the potential for microorganisms infiltrating their oxygen, nebulizer equipment and supplies causing a decline in physical health. The findings Included: Resident #3 Record review of Resident#3's MDS revealed he was a [AGE] year old male admitted to the facility on [DATE] with the following diagnosis of Pulmonary Disease (a group of diseases that cause air-flow blockage…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-22 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with currently accepted professional principles for 1 of 4 med carts reviewed. -The 300-hall medication cart was left unlocked. -CMA E left Resident #32's medication in a pill cup on her bedside table unattended. This failure could place residents who receive medications in the facility and place them at risk of receiving incorrect medications or ineffective therapeutic doses or drug diversion. The findings include: 1.Record review of Resident #32's face sheet revealed an [AGE] year-old female with an admission date of 10/20/2023. Diagnoses including dementia (a decline in cognitive abilities that impacts a person's ability to perform everyday activities), type 2 diabetes (high blood sugar), schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: 1. Opened food items were not placed in sealed containers and were not fully dated. 2. Floors and walls throughout the dietary department were soiled with food, grease, dust. 3. Shelf units were soiled with spilled spices, food, and had rusting surfaces. 4. The microwave oven and electric mixer were soiled with splattered food. 5. The low temperature dish machine did not have water temperatures and sanitizer levels consistently documented. 6. Cooking utensils and pans were stored with their sanitized surfaces exposed to contaminants in the air. 7. Ceiling air duct vent covers were soiled with dust build-up. This failure could place residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated. The findings included: Observations and interview during the initial tour of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-22 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident #'s 3 and 183) reviewed for infection control practices, in that: -LVN G failed to disinfect her glucometer between residents when doing fingerstick blood sugars. -LVN G failed to perform hand hygiene after glove changes and between residents when doing fingerstick blood sugars. These failures could place residents at risk for the spread of infection. The findings included: Resident #3: Record review of resident# 3's Quarterly MDS dated revealed he was a [AGE] year old male admitted to the facility on [DATE] with the following diagnosis of Diabetes (high level of sugar in the blood), He had a BIMS score of 11 which indicated moderate cognitive impairment. Resident #79: Record review of resident #79 '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.
- Potential for harm · D2023-12-22 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and record review, the facility failed to coordinate the assessment of one (Resident #72) of two residents with the pre-admission screening and resident review (PASRR) program. The facility did not identify Resident #72 as having a newly evident mental illness with a primary diagnosis of dementia after she acquired a new diagnosis that would require a new PASRR Level 1 (PL1) form or PASSR 1012 form be completed. This failure could affect residents with psychiatric diagnoses who may not be evaluated for PASRR services and place them at risk of not receiving services for care and treatment. The findings were: Review of Resident #72's Face Sheet and Orders dated 12/20/23 revealed she a was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #72's diagnoses included: dementia (thought process that interferes with daily function) which was added on 04/2/21, delusional disorder (altered reality), psychotic mood disorder with hallucinations…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-22 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #45) reviewed for comprehensive care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #45 after the resident was admitted with an order for oxygen. This failure could place residents at risk of not receiving care that is thoughtful, planned, and relevant to their condition(s) which could lead to complications in resident health and quality of life and care. The findings include: Record review of Resident #45's face sheet,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #2) of two residents reviewed for infection control practices. CNA H failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #2. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #2's face sheet dated 09/12/22, revealed an 81- year- old female admitted to the facility on [DATE] with diagnoses including overactive bladder, epilepsy, and dementia. Review of Resident #2's MDS assessment dated [DATE] revealed Resident #2 required limited assistance with most activities of daily living and one-person physical assistance with bed mobility and transfer. Resident #1 was always incontinent of bladder and frequently 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$91,080 in federal fines across 3 penalties.
- $54,919 — penalty dated 2025-03-06
- $23,941 — penalty dated 2023-12-22
- $12,220 — penalty dated 2023-09-13
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 AVIR HEALTH GROUP — 116 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.3 | -1.3 vs chain |
| Health inspection | 2 of 5 | 2.4 | -0.4 vs chain |
| Staffing | 1 of 5 | 1.8 | -0.8 vs chain |
| Quality measures | 2 of 5 | 3.6 | -1.6 vs chain |
The other 115 homes this chain runs (chain average 2.3★, per CMS)
Showing 40 of 115; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| 5455 KNICKERBOCKER RD LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | since 06/01/2024 |
| 5455 KNICKERBOCKER ROAD PROPERTY OWNER, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 03/01/2025 |
| WELLTOWER INC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 03/01/2025 |
| WELLTOWER NNN GROUP, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 03/01/2025 |
| WELLTOWER OP, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 03/01/2025 |
| APOLINAR, ADAM | Individual | CORPORATE DIRECTOR | since 06/01/2024 |
| 5455 KNICKERBOCKER ROAD OPCO, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2025 |
| CHANG, PETER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2025 |
| FREUND, NOCHUM | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 03/01/2025 |
| TRAVITSKY, AARON | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 03/01/2025 |
| DAGAN, AMITAI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 04/23/2025 |
| GOLDBERGER, ABRAHAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 04/23/2025 |
| KOFRON, CLAY | Individual | ADP OF THE SNF | since 03/01/2025 |
CMS files one row per role, so the 19 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676100. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, 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.