Morningside Manor
602 Babcock Rd, San Antonio, TX 78201 · Non profit - Corporation · 147 certified beds · (210) 731-1000 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- lower-than-typical staff turnover (16% vs 45% nationally) — better care continuity
- 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $5,000 in federal fines (most recent 2025-08-14)
- its facility-reported quality-measure score sits well above its independent inspection score
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 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 | 19.4% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.0% | 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 | 0.0% | 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 | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.3% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.4% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.0% | 18.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.4% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.9% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.5% | 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 | 85.6% | 88.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 28.4% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.7% | 12.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.66 | 2.17 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.66 | 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.
49.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 87 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 44 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 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 47% 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 | 49.4%CMS range 37.6–58.3 | 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 | 9.7%CMS range 6.5–13.7 | 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 | 68.2% | 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 | 70.5% | 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 | 54.5% | 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 | 98.4% | 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 | 100.0% | 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 | 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 | 1.6% | 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 | 6.6%CMS range 3.2–12.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.06 | 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 147 beds and averages 72.6 residents a day — about 49% occupied, or roughly 74 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 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.45 hrs/resident/day on weekends vs 3.66 on weekdays — 6% thinner on weekends. RN hours go from 0.35 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 16% is below 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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · D2026-04-11 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond 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 interviews and record reviews, the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 2 residents (Resident #1) reviewed for neglect. The facility failed to ensure the previous Executive Director A followed the facility's Abuse Prevention Program policy, when she did not complete an investigation of neglect that involved Resident #1 and did not submit a 3613A Provider Investigation Report to HHSC. This failure could place residents at risk of not being provided with services to meet their needs or prevent them from being neglected.Findings include: Record review of Resident #1's admission Record, dated 04/11/2026, revealed the resident was an [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included diabetes (chronic condition characterized…
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 · D2026-04-11 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
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 assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every three months for 1 of 4 (Resident #4) residents reviewed for MDS assessments. The facility failed to complete Resident #4's Quarterly MDS Assessment within three months of their most recent comprehensive assessment. This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information for their care plans. Findings included: Record review of Resident #4's admission Record, dated 04/11/2026, revealed the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included spinal stenosis (narrowing of the spinal canal compressing nerves causing pain, numbness and leg cramping), diabetes (chronic condition characterized by high blood sugar levels cause by insulin resistance or lack of insulin production), anemia (low levels 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.
- Potential for harm · E2025-08-07 · tag F0553 — failed to let residents help plan their care — patternAllow resident to participate in the development and implementation of his or her person-centered plan of 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 interview and record review, the facility failed to ensure the resident's right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. The right to participate in establishing the with the resident and the resident's representative for 3 of 5 residents (Resident #8, Resident #48, and Resident #69) reviewed for Comprehensive Care Plans in that: The facility failed to ensure Resident #8, Resident#48, and Resident #69 or the resident's representative were invited to participate in the residents' care plan meeting. This failure placed residents at risk for a loss of independence, psychosocial well-being, and the opportunity for them to participate in the planning of their care. Findings include:…
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 · E2025-08-07 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident had a right to secure and confidential personal and medical records for 6 (Residents #7, #9, #45, #61, #69, & #74) of 7 residents reviewed for privacy and confidentiality The facility failed to ensure the privacy and confidentiality of resident's clinical records that were not left on top of a treatment cart face up in the hallway unattended from 11:30 AM to 11:57 AM, for Resident #7, #9, #45, #61, #69, & #74 on 08/7/25. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy and confidentiality. Findings included: Record review of Resident #7's face sheet, dated 8/7/25, revealed a [AGE] year-old male with an initial admission of 09/14/23 and readmitted to the facility on [DATE]. His primary diagnosis was Altered mental Status, other diagnosis included Methicillin Resistant Staphylococcus Aureus infection as the cause of diseases classified elsewhere (MRSA is a type of bacteria…
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 · E2025-08-07 · tag F0641 — patternEnsure each resident receives an accurate assessment.
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 assessment accurately reflected the resident's status for 1 (Resident #8) of 5 residents reviewed for quality of care. 1. The facility failed to accurately assess Resident #8's bowel and bladder status. 2. The facility failed to accurately access Resident #8's ability to voice her bowel and bladder needs. These failures could place resident with having inaccurate care plans and inappropriate identification of care needs. Findings included: Review of Resident #8's annual MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Unspecified Injury of Head, Subsequent Encounter (a healthcare visit that occurs after the initial active treatment of a condition or injury; Type 2 diabetes mellitus without complications (a chronic condition that affects the way the body processes blood sugar - glucose); Essential (Primary) Hypertension (high blood pressure that is…
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 · E2025-08-07 · 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 observation, interview, and record review the facility failed to ensure enteral feeding physician orders were followed for 1 (Resident #12) of 7 resident reviewed for enteral tube feeding, in that: The facility failed to assess, obtain physician order, care plan, and obtain consent for Resident #12 to self-administer her bolus feedings via the g-tube two times a day. This failure could place residents with G-tubes at risk of needs not met and a decline in resident's health. Findings included: Record review of Resident #12's face sheet dated 8/14/25 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses were cirrhosis of the liver (chronic liver damage from a variety of causes leading to scarring and liver failure), type 2 diabetes, breast cancer, neoplasm of uncertain behavior of pharynx (throat cancer), and difficulty swallowing. Review of Resident #12's quarterly MDS dated [DATE] reflected Resident #12 had a BIMS of 15, indicating cognitive intact. She makes…
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 before2025-08-07 · 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 observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 9 reviewed for pharmaceutical services, in that: LVN A administered the expired insulin to Resident #4, Resident #22, and Resident #74. This failure could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level.Findings included: Review of Resident #4's face sheet, dated 8/6/2025, revealed the resident was a [AGE] year-old admitted on [DATE] with diagnoses of type 2 diabetes and stroke. Review of Resident #4's active order list, there was an order for Lantus Solostar Subcutaneous Solution Pen-injector 100unit/ml (insulin Glargine), start date 3/8/2025. Review of Resident #22's face sheet, dated 8/6/2025, revealed the resident was a [AGE] year-old female admitted 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 · E2025-08-07 · 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 label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 5 medication carts in that: Two insulin pens were not labeled with an open date in Unit 5 nurse med cart.Two insulin pens were expired in Unit 5 nurse med cart. These failures could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level.Findings included: Observation of Unit 5 med cart on 8/6/2025 at 9:06am revealed there were 2 insulin pens for Resident #4 and Resident #74 that did not have an open date on them. There were also 1 insulin pen for Resident #74 that was opened on 5/23/2025 and 1 insulin pen for Resident #22 that was opened on 6.24 In an interview with LVN A on 8/6/2025 at 9:07am, he stated that insulin pens should be labeled with an open date and once opened, the insulin pen should be discarded…
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 · E2025-08-07 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility must properly dispose of garbage and rubbish in accordance with current state laws for dumpster 1 of 2 reviewed for garbage disposal. The facility failed to ensure the doors on dumpster 1 were secured. This failure could place residents at risk of contracting disease by attracting pest and disease carrying rodents. Findings included: Observation on 08/05/25 at 8:36 AM, reflected the facility's dumpster area, which was outside of the dietary department to the right side of the parking lot were two commercial size dumpsters. Dumpster 1 had the left and right-side doors open which were 1/2 full of garbage. Interview on 08/05/25 at 8:40 AM, reflected the KD stated the dumpsters were for the entire facility and not just the kitchen. He stated the lids and doors on the dumpsters were supposed to be closed to keep all trash contained. He stated that the risk of the dumpster doors being opened could attract rodents. Interview on 08/05/25 at 3:31 PM, the FSS stated the kitchen and housekeeping were responsible for making 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.
- Potential for harm · Dcited before2025-08-07 · 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 for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 16 residents (Resident #1) reviewed for care plans. The facility failed to develop a person-centered care plan with interventions to address Resident #1's use of anti-coagulant medication, bed rails, and walker. This failure could have placed residents at risk of not having their needs identified and met. The findings included: Record review of Resident #1's admission Record/Face Sheet, dated 08/06/2025, revealed an [AGE] year-old female who originally admitted to the facility on [DATE] with most recent admission on [DATE]. Resident #1 was noted to have diagnoses of Alzheimer's Disease (a progressive brain condition that slowly damages your memory,…
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 16 citations
- Potential for harm · D2025-08-07 · 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 and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #45) of 7 residents reviewed for infection control. The facility failed to follow EBP (Enhanced Barrier Precautions) procedures for Resident #45 when the wound treatment team failed to wear PPE while providing wound care to Resident #45 on 08/07/25. This failure affected residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings included: Record review of Resident #45's face sheet, dated 8/7/25, revealed an [AGE] year-old male admitted on [DATE] with a diagnoses of primary osteoarthritis right shoulder (this is a type of arthritis that occurs when flexible tissue at the ends of bones wear down) and non-pressure chronic ulcer of right heal and midfoot…
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 before2024-06-30 · 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 observations, interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 16 (#6 , #3, #38, #56, #57, #120) in that: 1. Resident #6 received honey consistency liquids instead of nectar thick liquids. 2. Resident #3 did not have her 1/4 bed [NAME] in her care plan. 2. Resident #38 did not have her indwelling catheter in her care plan. 3. Resident #57 did not have her 1/4 bed rails in her care plan. 4. Resident #120 did not have her 1/4 bed rails in her care plan. 5. Resident #56 did not have his dentures mentioned…
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 · E2024-06-30 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span for 3 of 9 residents (confidential residents in group) reviewed for frequency of meals. The facility failed to ensure residents were offered snacks at bedtimes as required due to mealtimes being more than 14 hours apart. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. Findings included: Record review of the resident snack list (undated), was provided by the DM. There were 4 residents that received three times a day, to include HS snacks. The snack list provided by the DM were residents that had dialysis. There was no resident list with HS…
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 before2024-06-30 · 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, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. There were approximately 5 boxes that appeared to be less than 18 inches from the ceiling, in the walk-in fridge. 2. There was a chocolate pie that was not fully covered in the walk-in fridge. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: During observations and an interview in the initial tour of the kitchen with the CDM on 06/04/24 at 09:02 AM, there were approximately 5 cardboard boxes filled with various food products that appeared to be less than 18 inches from the ceiling, in the walk-in refrigerator. It was also observed there were 2 chocolate pies that were not completely wrapped, and their pie crusts were exposed. The CDM revealed the boxes should not be stored this close to the ceiling and the chocolate pies will be thrown away because she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-30 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 8 residents (Resident #54) reviewed for call lights. Resident #54 was placed in her room without access to her call light. On 06/05/2024 CNA P assisted Resident #54 in her wheelchair to her room and placed her out of reach of her call light. This failure could place residents at risk for harm by not having the ability to call for assistance. The findings included: A record review of Resident #54's admission record dated 06/06/2024 revealed an admission date of 04/01/2023 with diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), glaucoma (a condition where the eye's optic nerve, which provides information to the brain, is damaged and will cause gradual vision loss), atherosclerosis of the aorta (a condition characterized by the gradual…
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 · D2024-06-30 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 of 8 residents (Resident #6) reviewed for notification. On 03/23/24, LVN A and LVN C failed to notify the Medical Doctor 3 out of 7 neuro checks were not being done for 12 hours. Resident #6 was hospitalized on [DATE] and returned 03/27/24 with new diagnoses to include: cerebral infarction (a type of stroke caused by impaired blood flow to the brain), hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of one side of the body) following cerebral infarction affecting right dominant side , ataxia (a loss of muscle coordination), and slurred speech . An IJ was identified on 06/07/2024. The IJ template was provided to the facility on [DATE] at 09:00 PM. While the IJ was removed on 06/09/2024, the facility remained out of compliance at a scope of pattern and a severity level of potential harm because all staff…
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 · D2024-06-30 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 1 of 8 residents (Resident #54) reviewed for their right to voice grievances to the facility. CNA P failed to report and document Resident #54's complaint she was left without a call light, left unattended, and received rushed care. This failure could place residents at risk for harm by not having their grievances addressed. The findings included: A record review of Resident #54's admission record dated 06/06/2024 revealed an admission date of 04/01/2023 with diagnoses which included major depressive…
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 · D2024-06-30 · 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 interviews and record reviews the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 of 8 residents (Resident #6) reviewed for notification. The facility failed to ensure Resident # 6 was assessed as ordered for neuro-checks every 4 hours x 3 days. Resident # 6 was sent to hospital and returned to the facility on [DATE] with new diagnoses to include: cerebral infarction and hemiparesis following cerebral infarction affecting right dominant side, and slurred speech. An Immediate Jeopardy was identified on 6/29/2024 . The IJ template was provided to the facility on 6/29/2024 . While the IJ was removed on 6/30/2024, the facility remained out of compliance at a scope of pattern and a severity level lowered to no actual harm that is not Immediate Jeaperdy due to the facility's need to monitor and evaluate the effectiveness of the corrective actions. This failure could result in assessments not being completed as ordered 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 · Dcited before2024-06-30 · 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 reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident, for 1 of 7 residents (Resident #170) reviewed for pharmacy services. LVN U dispensed Resident #170's medications (11 pills) and stored them in a small pill cup in the medication cart with the intention of administering the medications at a later time and continued to dispense and administer medications for other residents. This failure could place residents at risk for harm by medication administration errors. The findings included: A record review of Resident #170's admission record dated 06/07/2024 revealed an admission date of 05/24/2024 with diagnoses which included hypertension (high blood pressure), diabetes type II (a condition where the body's cells cannot readily accept sugars from the blood), hyperlipidemia (a condition where 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 · D2024-06-30 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 a therapeutic diet was prescribed by the attending physician for 1 of 8 residents (Resident #6) reviewed for food and nutrition services. The facility failed to ensure Resident #6 had a physician's order for a pureed diet with nectar thickened liquids. The resident was prescribed a pureed diet with thin liquids and was provided a pureed diet with nectar thickened liquids. This deficient practice could place residents who are provided a modified texture diet at risk poor intake, and weight loss and diminished quality of life. The findings were: Record review of Resident #6's admission record, accessed 06/07/24, revealed the resident was admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing food or liquid) following cerebral infarction (a type of stroke caused by impaired blood flow to the brain) and mild protein-calorie malnutrition. Record review of Resident #6's significant change in status MDS, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-30 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 17 (Residents #25 and #57) residents in that: 1. Resident #25 did not have an order or care plan for diabetic shoes in her record. 2. Resident #57 did not have an order or care plan for diabetic shoes in her record. This failure could result in assessments not being completed as ordered could result in residents' not receiving the necessary care resulting in a decline in health and or death. This could affect all resident with assistive devices and could result in no orders for resident care. The findings included: 1. Record review of Resident #25's admission Record dated 6/7/2024 revealed the resident was admitted on [DATE], re-admitted on [DATE] with diagnosis of Diabetes II. Record review of Resident #25's consolidated physician orders for June 2024 revealed no order…
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 · E2023-04-21 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility faield to ensure resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for for 3 of 21 (Room#243, Room#237 and room [ROOM NUMBER]) resident rooms during initial rounds in that: 1. room [ROOM NUMBER]'s bathroom, the shower chair had black substance on the back side of the nylon mesh used to hold up body in place and at the bottom side of shower chair. 2. room [ROOM NUMBER]'s bathroom shower curtain had black substance on it. 3. room [ROOM NUMBER]'s bathroom shower curtain had brown substance on it. This could affect residents and place residents at risk for infections. The Findings included were: 1.Observation on 4/18/2023 at 11:28 AM in room [ROOM NUMBER] the shower curtain had black substance on it. (alongside of mesh seems that meet plastic pipes) 2.Observations on 4/18/2023 at 11:35 AM in room [ROOM NUMBER]'s bathroom, the shower chair…
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 · E2023-04-21 · tag F0759 — failed to keep medication error rate low — patternEnsure 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 reviews the facility failed to ensure a medication error rate below 5% for 2 of 8 Residents (Residents #25 and #36) reviewed for medication administration errors, in that: The Facility staff administered 28 medications of which 7 were administered to Residents #25 and # 36, 1 to 1.5 hours after they were scheduled, which resulted in a 27% medication error rate. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: Resident #25 A record review of Resident #25's face sheet, dated 04/20/2023, revealed an admission date of 11/20/2020, with diagnoses which included acute kidney failure, major depressive disorder, type II diabetes [a disease which the body cannot use sugar due to poor insulin levels result in too much damaging sugar in the blood], glaucoma [a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called…
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 before2023-04-21 · 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, interview and record review revealed the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens in that: 1. Ice machine had a pink film across the lip of the ice shoot. 2. Low temperature dishwasher temperature for wash cycle was 114 degrees Fahrenheit and 115 degrees Fahrenheit. should have been 120 degrees Fahrenheit. 3. The Dish machine log was not completed. 4. Dietary aid _G_ was at dish machine and had several jewelry on, such as rings and bracelets. This failure could place residents at risk of cross contamination Ns food borne illness. The Findings included were: 1. Observation on 4/18/23 at 9:45 AM to 10:00 AM during the initial tour of kitchen with the CDM and the FSM revealed the following: a. the ice machine had a pink film across the lip of the ice machine. b. The dishwasher was a low temperature machine running the wash cycle was at 114 degrees Fahrenheit. c. the dish machine log was missing temperatures from 4/15/2023-4/16/2023 for the dinner temperature…
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 · D2023-04-21 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 70 (Resident #53) residents reviewed for MDS transmittal in that: Resident #53's 5-day MDS assessment dated [DATE] and discharge MDS assessment dated [DATE] was not submitted as of 4/21/2023. This deficient practice could place residents at risk of not having their assessments transmitted timely. Findings included: Record review Resident #53's admission record dated 4/20/2023 revealed he was admitted on [DATE] and readmitted on [DATE] with a discharge date d 1/8/2023. Resident #53's diagnoses included shortness of breath, fluid overload, acute respiratory failure, acute pulmonary edema, pleural effusion, dysphasia, cognitive communication deficit, chronic kidney disease, altered mental status, diabetes II, dependence of renal dialysis, anemia, major depressive disorder, end stage renal disease, and anemia. 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 · Dcited before2023-04-21 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interviews and record reviews the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized, for 1 of 8 Residents (Resident #19) reviewed for complete and accurate medical records, in that: Resident #19 medical record was missing 7 of 16 weekly Skin Assessments since 1/01/2023. This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors or delays in care and treatment. The findings included: Record review of Resident #19's admission Record revealed she was an [AGE] year-old female and was admitted to the facility on [DATE]. Record review of Resident #19's quarterly MDS dated [DATE] revealed primary reason for admission was non traumatic brain dysfunction related to dementia. Cognitive Patterns section revealed Resident #19 was unable to complete BIMS assessment. Functional Status section for bathing revealed Resident #19 was at total…
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
$5,000 in federal fines across 1 penalty.
- $5,000 — penalty dated 2025-08-14
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GUADALUPE COUNTY HOSPITAL BOARD | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/01/2017 |
| BRYAN, SCOTT | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2024 |
| DROUGHT, JESSICA | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2023 |
| FORGIONE, DANA | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2023 |
| GARZA, EDWARD | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2021 |
| HACKETT, GREG | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2022 |
| KERCHEVILLE, SCOTT | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2022 |
| MCCULLOUGH, ROBERT | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2024 |
| MCRAE, THOMAS | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2024 |
| MENDOZA, DORA | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2022 |
| MOBLEY, JESSICA | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2023 |
| MOORE, JOE | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2024 |
| ORTIZ, ROBERT | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2024 |
| PHIPPS, AMY | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2024 |
| RAGSDALE, VICKIE | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2025 |
| READ, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2022 |
| SCOFIELD, GEORGE | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2022 |
| TYE, RICHARD | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2020 |
| YOUNGQUIST, HOLLY | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2023 |
| COLVIN, JIM | Individual | CORPORATE DIRECTOR | — | since 07/25/2023 |
| GANN, KODY | Individual | CORPORATE DIRECTOR | — | since 01/01/2021 |
| HUMPHREY, RONALD | Individual | CORPORATE DIRECTOR | — | since 03/01/2022 |
| MAJOR, DOLORES | Individual | CORPORATE DIRECTOR | — | since 03/01/2019 |
| RAMIREZ, LOUIS | Individual | CORPORATE DIRECTOR | — | since 03/01/2021 |
| REYES, JAMES | Individual | CORPORATE DIRECTOR | — | since 04/05/2022 |
| WALLACE, PENNY | Individual | CORPORATE DIRECTOR | — | since 03/01/2025 |
| CATTAIL CONSULTING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/10/2023 |
| MORNINGSIDE MINISTRIES | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2017 |
| MORRISON MANAGEMENT SPECIALISTS INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2024 |
| QUALITY REHAB MANAGEMENT | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/23/2023 |
| ASIS, RISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/03/2023 |
| CRUMP, PATRICK | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2017 |
| FLORES, CRISTINA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/27/2023 |
| HOPPE, KIMBERLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2024 |
| MORENO, CHELSEA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/30/2023 |
| NGUYEN, CHRISINE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/19/2018 |
| SANCHEZ, JUANITA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/02/2023 |
| TOLAN, BRENDA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/12/2023 |
| MUNOZ, DIONICIO | Individual | ADP OF THE SNF | — | since 09/24/2023 |
CMS files one row per role, so the 60 rows in the source record cover these 39 parties — each is shown once here with every role it holds. Nothing is omitted.
5 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 455523. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-07, 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.