Park Plaza Nursing And Rehabilitation Center
2210 N Howard St, San Angelo, TX 76901 · For profit - Corporation · 90 certified beds · (325) 944-0561 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (85%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 1 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.6% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.7% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.8% | 0.8% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.7% | 2.4% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.6% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.4% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 6.7% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 13.3% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.5% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 31.5% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.6% | 12.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.22 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.28 | 2.06 | 1.80 | better |
‡ 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.
Met the expected recovery: 59.3% 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 27 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 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 7.8–15.9 | 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 | 59.3% | 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 | 70.4% | 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 | 29.6% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.4% | 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 | 8.3%CMS range 5.2–13.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.15 | 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 90 beds and averages 40.2 residents a day — about 45% occupied, or roughly 50 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.
Weekend coverage: total nurse staffing is 3.01 hrs/resident/day on weekends vs 3.45 on weekdays — 13% thinner on weekends. RN hours go from 0.58 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 85% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · D2026-05-14 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 had the right to personal privacy and confidentiality of his or her personal and medical records for 2 of 5 residents (Resident #2 and Resident #43) reviewed for privacy, in that:The facility failed to ensure LVN A locked the computer, which exposed Resident #2's morning medication list after she walked away and left the computer unattended.The facility failed to ensure LVN B locked the computer, which exposed Resident #43's lunch time medication list after she walked away and left the computer unattended.This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected.The findings include:Record review of Resident #2's face sheet dated 5.12.26 reflected an 85 - year old female who was admitted to the facility on 11.7.25 with diagnoses which included: Chronic Obstructive Pulmonary Disease (lung disease that damages the airways or other parts of the lungs, making it difficult to breathe), Respiratory Failure,…
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 before2026-05-14 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 it was determined the facility failed to provide pharmaceutical services that ensure the accurate administering of drugs for 1 of 2 nurse medication carts (South Hall) observed for medications stored. properly labeled and accounted for. The South Hall nurse medication cart had two controlled medication blister packs that did not match their corresponding controlled medication count sheet. This failure could place residents at risk of underdose, overdose or drug diversion. Findings included: Review of Resident #4's admission record dated 05/14/2026 revealed the resident was admitted to the facility on [DATE] with diagnosis of pain. He was [AGE] years of age. Review of the current care plan for Resident #4, last reviewed/revised: 03/25/2026, revealed in part: The resident is on Pain medication. The resident will be free of any discomfort or adverse side effects from pain medication through the review date. Administer medication as ordered. Review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication carts (South hall) reviewed for medication storage. The south hall nurse medication cart had one insulin pen that belonged to Resident #5 that had been opened but not dated when it was placed into use. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: Review of Resident #5's admission record dated [DATE] revealed he was admitted to the facility on [DATE] with diagnosis of diabetes. He was [AGE] years of age. Review of the current care plan for Resident #5, last reviewed/revised: [DATE], revealed in part: The resident has Diabetes. Diabetes medication as ordered by doctor. Monitor/document for side…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 observation, interview, and record review the facility failed to ensure 1 of 7 residents (Resident #36) with indwelling urinary catheters received appropriate care to prevent urinary tract infections to the extent possible. Resident #36's indwelling catheter tubing was dragging on the floor on 3 of 3 days observed. This failure could place residents with indwelling urinary catheters at risk of infection. The findings included: Resident #36 Record review of Resident #36's admission record dated 03/13/25 indicated he was admitted to the facility on [DATE] with diagnoses of muscle weakness, reduced mobility and retention of urine. He was [AGE] years of age. Record review of Resident #36's care plan dated 10/17/2024 indicated in part: Focus: The resident has an indwelling catheter. Goal: The resident will be/remain free from catheter-related trauma through review date. Interventions: Check tubing for kinks and maintain the drainage bag off the floor. Record review of Resident #36's annual MDS 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.
- Potential for harm · D2025-03-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, 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 for 1 of 4 (Resident #3) reviewed for respiratory care. Resident #3's oxygen nasal cannula and SVN mask were not covered in a plastic bag when they were not used. These failures could place all residents who use respiratory equipment at risk for respiratory infections. The findings included: Record review of Resident #3's admission record dated 03/13/25 indicated she was admitted to the facility on [DATE] with diagnoses of muscle weakness and hypoxemia (Low blood oxygen). She was [AGE] years of age. Record review of Resident #3's care plan dated 10/17/2024 indicated in part: (Focus: Resident has impaired oxygen exchange and shortness of breath r/t COPD and hypoxemia. Uses oxygen @ 3 liters per minute continuously when asleep & PRN during the daytime. Goal: Resident will have adequate air exchange as evidenced 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 · Dcited before2025-03-13 · 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 2 nurse medication carts (The north hall medication cart) reviewed for medication storage and security. LVN C failed to ensure the nurse medication cart for the north hall was secured when it was left unattended. These failures could place residents at risk for drug diversion or accidental ingestion. Findings included: During an observation on 03/11/25 at 10:20 AM the nurse medication cart on the north hall was observed unlocked and unattended. During an observation and interview on 03/11/25 10:25 AM LVN C was observed coming out of a resident's room. LVN C said that it was her nurse medication cart and it was her that had accidentally left it open. LVN C said she had stepped away to help one of the staff members and had forgotten to lock the cart. LVN C said leaving the cart unlocked and unattended could lead to unauthorized people having access of the cart. Inside the cart were several bubbled packed prescribed medications, insulin pens and other…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-13 · 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 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 1 (Resident #36) of 7 residents reviewed for infection prevention and control. CNA A and CMA B failed to change her gloves when going from dirty to clean during Resident #36's incontinent care. CNA A and CMA B failed to use PPE during incontinent care and urinary catheter care performed for Resident #36 as the resident was on EBP precautions. These failures could place residents at risk of infections, secondary infections, and communicable diseases. Finding include: Record review of Resident #36's admission record dated 03/13/25 indicated he was admitted to the facility on [DATE] with diagnoses of muscle weakness, reduced mobility, and retention of urine. He was [AGE] years of age. 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.
- Potential for harm · Dcited before2024-04-01 · 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 one (Resident #1) of three residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1 on 03/29/24. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 04/01/24, revealed an 84- year- old female admitted to the facility on 06/06//22 with diagnoses including Covid-19, overactive bladder, gastronomy (feeding tube) and dementia. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 required total assistance with most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #1 was always incontinent…
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 · E2024-02-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 4 residents (Resident #13 & Resident # 45) reviewed for dignity. The facility failed to ensure staff treated Resident #13 & Resident #45 with dignity by covering their catheter bags with privacy bags. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem. The findings included: Record review of Resident # 13's face sheet dated 02/09/2024 revealed, [AGE] year-old female admitted on [DATE] with diagnosis: neuroleptic induced parkinsonism (disorder of the brain that affects the functioning of muscles) and Neuromuscular dysfunction of bladder (disorder of the brain that affects functioning of the bladder). Record review of Resident # 13's comprehensive MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed 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 · E2024-02-09 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
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 reviews and interviews, the facility failed to thoroughly investigate allegations of Abuse and Neglect and Injury of Unknown Origin for 6 of 11 residents (Resident #6, #17, #20, #37, #27 and #42) reviewed. The facility did not have documentation that thorough investigations of allegations of Neglect for Resident #,6, #17, #20, #37, #27 and #42 were completed. This failure could place residents who report allegations of abuse at risk of not being thoroughly investigated. Findings included: Resident #6 Record review of Resident #6's electronic face sheet dated 02/07/2024 revealed the resident was a [AGE] year-old female who was admitted on [DATE] and an original admission date of 10/28/2022 with diagnoses that included: Chronic Obstructive Pulmonary Disease (airflow blockage and breathing related problems), muscle weakness, Lack of Coordination, violent behavior, spastic hemiplegia (muscle tightness and involuntary contractions in the limbs and extremities on one side of the body) affecting left…
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 18 citations
- Potential for harm · E2024-02-09 · 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 person-centered, comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 5 (Resident # 32, Resident #33, Resident #44, Resident #48, and Resident #49) of 5 residents reviewed for care plans. The facility failed to ensure care plans specified measurable objectives that could be evaluated or quantified for Resident #32, Resident #33, Resident #44, Resident #48, and Resident #49. The facility failed to ensure care plans specified measurable objectives that could be evaluated or quantified with a timeframe to achieve for Resident #32, Resident #33, Resident #44, Resident #48, and Resident #49. These failures could place residents at risk for not receiving timely interventions or interventions not individualized to meet their specific…
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 · E2024-02-09 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 review and revise resident-centered comprehensive care plans within 7 days of a comprehensive assessment for 5 (Resident #13, Resident #32, Resident #44, Resident #48, and Resident #49) of 6 residents reviewed for care plans. The facility failed to review and revise Resident #13, Resident #32, Resident #44, Resident #48, and Resident #49's Comprehensive Patient-Centered Care Plan within 7 days following the completion of a comprehensive assessment. This failure could put residents at risk for not receiving the care and services needed to maintain or improve physical, mental, emotional, psychological well-being. Findings included: Record review of Resident #13's electronic face sheet revealed a [AGE] year-old female, initially admitted on [DATE] with her most recent admission on [DATE]. Resident #13 was admitted with medical diagnoses that included kidney disease, bipolar disorder, major depression, low thyroid function, drug induced involuntary muscle…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-09 · tag F0687 — failed to care for feet properly — patternProvide appropriate foot care.
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 proper treatment and care to maintain mobility and good foot health for 1 of 3 residents (Resident #42) reviewed for foot care. The facility failed to ensure Resident #42 received podiatry care since admission on [DATE]. This deficient practice could place residents at risk of overall poor foot hygiene and a decline in resident's physical condition. The findings were: Record review of Resident #42's face sheet, dated 02/09/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with the following diagnoses which included type-2 diabetes, hemiplegia (weakness) and hemiparesis (paralysis) to right dominant side, stroke and lack of coordination. Record review of Resident #42's Quarterly MDS Assessment, dated 01/11/2024, revealed Section C- Cognitive Patterns Resident #42 had a BIMS score of 15 (cognitively intact); Section G: ADL Assistance revealed Resident #42 had functional limitation in…
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 · E2024-02-09 · 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 observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 5 (Residents #3, #6, and #18) residents reviewed for smoking safety. The facility failed to ensure Residents #6 was supervised when smoking per assessment. The facility failed to ensure Residents #3, #6, and #18's lighters and cigarettes were not stored on their person. These failures could affect residents who smoke at risk of serious bodily harm, physical impairment, or death. The findings included: Resident #3 Record review of Resident #3's electronic face sheet dated 02/09/2024 revealed resident was a [AGE] year-old female who was admitted on [DATE]. Resident #3's diagnoses included: Chronic Obstructive Pulmonary Disease. Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns Resident #3 had a BIMS score of 15 (cognitively intact). Section GG-Functional Abilities and Goal: Resident #3 used a manual wheelchair.…
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 before2024-02-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 observation, interview and record review the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #40) of 4 residents reviewed for catheters. The facility failed to provide appropriate treatment and indwelling catheter services consistent with professional standards of practice by not changing Resident #40's urinary catheter as ordered and ensuring Resident #40's urinary catheter collection bag was not on the floor. This failure placed residents with urinary catheters at risk for infection threatening their physical and mental well-being. Findings included: Record review of Resident #40's electronic face sheet revealed a [AGE] year-old female admitted [DATE] with medical diagnoses of a stroke, high blood pressure, paralysis in both arms and legs, neuromuscular dysfunction of the bladder (lacking control of the muscles that control bladder function due to brain, spinal cord, or nerve problems),…
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 · E2024-02-09 · tag F0693 — failed to provide proper feeding-tube care — patternEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 that a resident who uses a feeding tube for liquid nourishment, fluids, and medications received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 (Resident #40) reviewed for gastrostomy tube. The facility failed to check the placement of Resident #40's gastrostomy tube prior to administering water flushes and medication administration via gastrostomy tube. This failure could place residents who use gastrostomy tubes at risk of aspiration pneumonia. The findings included: Record review of Resident # 40's face sheet dated 02/09/2024 revealed, [AGE] year-old female admitted on [DATE] with diagnosis: dysphasia following other cerebrovascular disease (difficulty swallowing after stroke) and dysphagia, oropharyngeal phase (difficulty swallowing). 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 · E2024-02-09 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 attempt to use alternatives prior to installing a side or bed rail and assess the resident for risk of entrapment from bed rails prior to installation for 3 of 3 residents (Resident #20, Resident #25, and Resident #45) reviewed for bed rails. The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails. These failures could place residents at risk for injury and restricted movement. The findings include: Resident #20 Record review of Resident #20's face sheet dated 02/09/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's Disease (disease that destroys memory and other important mental functions), muscle weakness, and lack of coordination. Record review of Resident #20's quarterly MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS assessment revealed a score of 0 meaning…
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 before2024-02-09 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 with PRN orders for psychotropic drugs were limited to 14 days and to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 2 (Resident #20) residents reviewed for unnecessary medications. The facility failed to ensure Resident #20's PRN lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication that was not indicated for use to treat medical conditions and symptoms and dependence on unnecessary medications. Findings included: Resident #20 Record review of Resident #20's face sheet dated 02/09/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] 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 before2024-02-09 · 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
Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication storage rooms (North hall medication room) and 1 of 4 medication carts (South nurse medication cart) reviewed. The facility failed to ensure that medications were secured in locked medication cart. The facility failed to ensure that medications were stored in an environment that was dry and without ice buildup. These failures could place residents who receive medications at risk for receiving the wrong medications, outdated medications or contaminated medications which could result in residents not receiving the intended therapeutic effects medications or harm. Findings included: During an observation / interview on 02/06/2024 at 10:37 a.m. revealed the South Hall medication cart sitting in front of the South Hall nurses' station unattended. On the top of medication cart had one bubble pack of trazadone (medication used for insomnia and depression) 50mg with 3 tablets in…
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 · E2024-02-09 · tag F0770 — failed to provide lab services — patternProvide timely, quality laboratory services/tests to meet the needs of residents.
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 or obtain laboratory services to meet the needs of 1 of 2 (Resident #25) residents reviewed for lab services. The facility failed to provide or obtain lab work as ordered by the physician for Resident #25. This failure could place the residents at risk of missed labs, depriving their physician of monitoring important levels. Findings included: Record review of Resident #25's face sheet dated 02/07/2024 revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnoses which included type 2 diabetes (disease that resulted in too much sugar in the blood). Record review of Resident #25's quarterly MDS dated [DATE] Section C (Cognitive Patterns) BIMS assessment revealed a score of 9 indicated moderately impaired and Section I (Active Diagnoses) included diabetes. Record review of Resident #25's comprehensive care plan reviewed on 02/07/2024 revealed 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.
- Potential for harm · E2024-02-09 · 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 properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. The facility failed to ensure food was not past expiration date. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 02/06/2024 from 9:30 AM to 10:00 AM of the kitchen revealed: Refrigerator #1 1. A container of Chorizo that was opened with a use by date of 01/24/2024. 2. A container of ranch dressing not in the original container date open on 01/26/24 not labeled with use by date. 3. An open container of sour cream with a use by date of 02/02/2024. 4. A plastic container with a lid that contained three 5-pound packages of ground hamburger meat dated 01/29/2024. 5. A plastic container with a lid that contained green chilies, out of original container, labeled 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 · E2024-02-09 · tag F0868 — patternHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 3 of 12 meetings (11/23,12/2023, and 01/2024) reviewed for QAPI. The facility did not ensure the MD, or a representative attended QAPI meetings on 11/23, 12/2023, and 01/2024. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings include: Record review of the facility's QAPI Committee sign-in-sheets for 11/23, 12/2023, and 01/2024 indicated the MD or a representative did not sign in for the meetings. During an interview on 02/08/2024 at 1:45 PM the ADMN stated the Physician participated the monthly QAPI meetings by telephone and they did not have any documentation. He stated he could have the physician come into the facility to sign the logs. He stated the staff would sign their name on the QAPI list but did not place their titles. He stated the Medical Director should have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-09 · tag F0909 — failed to maintain a comfortable temperature — patternRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
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 conduct regular inspections of all bed frames and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 4 of 4 (Residents #9, #20, #25 and #45) residents reviewed for bed rails. The facility did not conduct regular inspections of bed rails, including Residents #9, #20, #25 and #45's beds. This failure could place residents who have bed rails at risk for injury related to poor maintenance of the bed rails. The findings included: Resident #9 Record review of Resident # 9's face sheet dated 02/09/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with an original admission date of 07/10/2020 with diagnoses which included Heart failure, Kidney failure and high blood pressure. Record review of Resident #9's quarterly MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS score of 15 (cognitively intact); Section GG (Functional Abilities) revealed Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-09 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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
Based on observation, interview and record review the facility failed to provide pharmaceutical services including procedures that assure accurate administering of medications for 2 of 4 medication carts (South nurse medication cart, & North nurse medication cart) reviewed. The facility failed to ensure expired medications were removed from medication carts. These failures could place residents who receive medications at risk for receiving outdated medications which could result in residents not receiving the intended therapeutic effects medications. Findings included: During an observation / interview on 02/06/2024 at 11:41 a.m. revealed the South Hall nurses' cart had diphenhydramine (medication used for itching and allergic symptoms) 25mg bottle with expiration date not visible. LVN G stated she was not able to read the expiration date on the medication bottle. She stated she did not know when medication expired, and that medication should not be stored on cart without visible expiration date. She did not know why medication was on the cart but should not be administered without…
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 before2023-11-20 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 record review and interview, the facility failed to provide pharmaceutical services, including the accurate administering of drugs for 1 of 5 Residents (Resident #1) reviewed for pharmacy services. 1) The facility failed to ensure Licensed Vocational Nurse (LVN) A did not administer PRN Ativan (Anti-Anxiety/Sedative medication), after it was ordered to be discontinued. The facility failed to remove anti-anxiety (Ativan) medication from the medication cart after it was ordered to be discontinued by the physician for Resident #1 The noncompliance was identified as past noncompliance. The noncompliance began [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the investigation began. These failures could place residents who received medications at risk of receiving unnecessary doses of medication, experiencing undesirable side effects as well as potentially causing a physical or psychological decline in health. Findings include: Review of Resident #1's face sheet, care plan, 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 · D2023-09-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 interview and record review, the facility failed to ensure 1 of 4 residents (Resident #1) received treatment and care in accordance with professional standards of practice reviewed. 1) CNA A failed to stop attempting to perform the care being resisted by Resident #1 during incontinent care. This failure could place residents at risk for being provided care or treatment different from the plan of care. Findings Include: Review of Resident #1's face sheet dated 09/07/2023 revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included vascular dementia (impaired blood flow to brain) Alzheimer's Disease and Type II Diabetes. Review of Resident #1's MDS assessment dated [DATE] revealed she had a brief interview for mental status score of 99 indicating Resident #1 was not able to complete the BIM's interview. Resident #1 has minimum difficulty hearing with unclear speech Resident #1 has physical behaviors directed towards others e.g., hitting, kicking, pushing,…
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 before2023-09-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 reevaluate and implement non-pharmacological interventions with the use of a PRN antipsychotic drug, for 1 Resident (R#1) of 6 residents reviewed for antipsychotic medications, in that: 1) The facility administered an anti-anxiety medication (Ativan) PRN (as needed) to Resident #1, for more than 14 days, without an evaluation by Resident#1's Physician for the appropriateness of the medication. 2) Facility failed to implement behavioral interventions and assess resident reaction to interventions prior to administering anti-anxiety medication (Ativan) PRN (as needed) to Resident #1. These failures could place residents who received psychotropic medications at risk of receiving unnecessary doses of medication, experiencing undesirable side effects as well as potentially causing a physical or psychological decline in health. The Findings Include: Review of Resident #1's face sheet dated 09/07/2023 revealed Resident #1 was a [AGE] year-old female admitted…
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.
- No harm found · C2024-02-09 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and observation, the facility failed to ensure staffing information was posted daily, readily accessible to residents and visitors that included: the total number and the actual hours worked by the Registered nurses, Licensed Practical nurses or Licensed Vocational Nurses or Certified Nurse Aides directly responsible for resident care per shift for 3 of 3 days (02/06/2024, 02/07/2024, and 02/08/2024 reviewed for staffing information. The facility failed to ensure the daily staffing information was posted daily on 02/06/2024, 02/07/2024, and 02/08/2024. This failure could place residents, their families, and visitors at risk of not having the staffing information readily accessible for review, residents and visitors are not able to know how many staff are currently working to provide care on all shifts. Findings Included: Observation on 02/06/2024, 02/07/2024 and 02/08/2024 of the nurses station and hallways revealed evidence of the daily staffing hours posted was last dated 01/01/2024. During an interview on 02/07/2024 at 3:48 PM the ADMN stated he was not sure…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to CREATIVE SOLUTIONS IN HEALTHCARE — 149 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.1 | +0.9 vs chain |
| Health inspection | 4 of 5 | 2.7 | +1.3 vs chain |
| Staffing | 1 of 5 | 1.1 | -0.1 vs chain |
| Quality measures | 4 of 5 | 3.2 | +0.8 vs chain |
The other 148 homes this chain runs (chain average 2.1★, per CMS)
Showing 40 of 148; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BALLINGER MEMORIAL HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/01/2024 |
| ATWOOD, MARK | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2025 |
| BUNDRANT, BRADLY | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2025 |
| DANKWORTH, MIKE | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2025 |
| FRICKE, RHETT | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | — | since 02/01/2024 |
| HUNTER, WILLIAM | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2025 |
| REASOR, TYLER | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2025 |
| STUDER, SCOTT | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2025 |
| ZUNIGA, ELIZABETH | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2025 |
| HUGGINS, LINDA | Individual | CORPORATE DIRECTOR | — | since 02/01/2024 |
| WILLIG, ZACHARY | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| SAN ANGELO I ENTERPRISES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2024 |
| BLAKE, GARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2024 |
| BLAKE, MALISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2024 |
| AGUILAR, ROLANDO | Individual | ADP OF THE SNF | — | since 04/14/2025 |
| HUNT, JOHN | Individual | ADP OF THE SNF | — | since 04/14/2025 |
CMS files one row per role, so the 19 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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.
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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675982. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, 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 →
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