Pecan Valley Rehabilitation And Healthcare
3838 E Southcross Blvd, San Antonio, TX 78222 · For profit - Corporation · 124 certified beds · (210) 581-2273 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
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (25) — 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)
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 | 5 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 5.0% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.0% | 3.0% | 5.4% | worse |
| 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 | 0.9% | 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 | 0.8% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.0% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.5% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.8% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 12.6% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.8% | 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 | 93.9% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.6% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 4.2% | 12.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.11 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.43 | 2.06 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
52.3% 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 84 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.1% 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 49 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 0.59 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% 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 | 52.3%CMS range 42.1–63.3 | 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 | 10.8%CMS range 7.7–14.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 53.1% | 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 | 49.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 46.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.7% | 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 | 96.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 | 2.2% | 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 | 6.7%CMS range 3.8–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 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 124 beds and averages 104.3 residents a day — about 84% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.72 hrs/resident/day on weekends vs 3.70 on weekdays — 27% thinner on weekends — a notable drop. RN hours go from 0.36 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · J2025-07-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #1) reviewed for accidents and hazards: The facility failed to ensure Resident #1's environment was free of choking hazards when Resident #1 expired on 6/24/2025 as a result of asphyxiation by choking[PH1] [SA2] . An Immediate Jeopardy (IJ) was identified as past non-compliance on 7/07/2025. The Noncompliance began on 6/24/2025 and ended on 6/25/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health and or death. The findings included: Record review of Resident #1's face sheet dated 6/24/2025 revealed a 72- year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: unspecified dementia unspecified severity without behavioral disturbance, psychotic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-29 · 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 interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 3 residents (Residents #1 and #2) reviewed for pharmacy services. 1.The facility failed to ensure Resident #1's prescribed medications of Insulin Glargine Subcutaneous Solution and NovoLOG Injection Solution 100 UNIT/ML were administered according to physician orders for the months of February 2026 - April 2026.2.The facility failed to ensure Resident #2's prescribed medications of Insulin Glargine and NovoLOG FlexPen Subcutaneous were administered according to physician orders for the month of April 2026. These failures could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.The findings included:1. Record review of Resident #1's admission Record dated 04/28/2026 revealed a [AGE] year-old male…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-29 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 3 residents (Residents #1 and #2) reviewed for medical records. 1.The facility failed to maintain progress notes and documentation of notification to physician when medication errors were identified for Resident #1's prescribed medications, Insulin Glargine Subcutaneous Solution and NovoLOG Injection Solution 100 UNIT/ML for the months April 2026.2.The facility failed to maintain progress notes and documentation of notification to physician and management team when medication errors were identified for Resident #2's prescribed medications, Insulin Glargine and NovoLOG FlexPen Subcutaneous for the month of April 2026. These failures placed residents at risk for missed treatment and medications which could result in decline in health and well-being.The findings included: 1. Resident Record review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-30 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 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 conduct an initial comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity for one of 32 residents (Resident #45) reviewed for comprehensive assessments.The facility failed to complete and transmit an admission assessment for Resident #45 within 14 days of the resident's admission.This failure placed residents at risk of not having their needs, strengths, goals, life history and preferences assessed to ensure they received appropriate care.The findings included:Record review of Resident #45's electronic face sheet dated 01/28/2026 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including open would on lower left leg, Type 2 diabetes with hyperglycemia (high blood sugar levels), bipolar disorder (a mental health condition that causes extreme mood swings) and morbid obesity (an excess of 80 to 100 pounds above ideal body weight). No previous admission date…
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 · D2026-01-30 · 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 interviews and record reviews, the facility failed to ensure an encoded, accurate and complete discharge MDS was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 4 residents (Resident #20) reviewed for discharge MDS assessments.The facility failed to ensure a discharge MDS was completed and transmitted for Resident #20's within 14 days of his discharge to the hospital.This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required.The findings included:Record review of Resident #20's electronic face sheet, accessed on 01/27/2026, revealed the resident was a [AGE] year-old male admitted on [DATE] with diagnoses that included epilepsy (seizures), Type II diabetes (a problem in the way the body regulates and uses blood sugar), acute respiratory failure (a life-threatening condition that occurs when fluid leaks from small blood vessels in the lungs and builds up in the air sacs) and cerebral…
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 · D2026-01-30 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one resident (Resident #53) reviewed for range of motion. The facility failed to ensure Resident #53's right hand splint (medical device used to treat hand contractures, permanent tightening of the muscles, tendons, skin and surrounding tissues that causes stiffness, placed in the hands to help improve range of motion) was in place to her right hand. This failure could place the resident at risk for decrease in mobility and range of motion and contribute to worsening of contractures. Record review of Resident #53's Face Sheet dated 01/29/26, documented a [AGE] year-old female originally admitted to the facility on [DATE] with her last admission date of 07/30/25. Resident #53's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right…
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 · D2026-01-30 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
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 the safe and sanitary storage of residents' food items in 1 of 5 residents' refrigerators reviewed. The personal refrigerator in the resident's room [ROOM NUMBER]A contained unlabeled, undated food items. This failure could place residents at risk of foodborne illness from consuming spoiled food. The findings were: Observations on 1/27/2026 at 9:35 a.m. revealed that the personal refrigerator in RM [ROOM NUMBER] A contained cooked beef and white pasta in an unlabeled, undated storage container. Further observations on 1/27/2026 at 11:30 a.m. of the personal refrigerator in RM [ROOM NUMBER] A revealed that the cooked beef and white pasta in an unlabeled, undated storage container were still present. An interview with Resident # 104 on 01/27/2026 at 9:40 a.m. revealed that she could not recall how long the cooked beef and white pasta had been in her personal refrigerator, but recalls that her daughter, who visits often, leaves…
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 before2025-11-24 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 of 1 kitchen reviewed for sanitation. The facility failed to ensure the Dietary Manager used hair restraints properly while working in the kitchen. This failure could place residents who received meals or snacks from the kitchen at risk for food borne illness.The findings included: During an observation of the facility kitchen on 10/14/25 at 11:30 AM, the Dietary Manager (DM) was observed wearing a hair restraint over only part of her hair during meal preparation. The dietary manager wore a hair restraint over her ponytail but did not have a hair restraint covering the rest of her head. During an interview with the DM on 10/14/25 at 11:35 AM, the DM stated her expectation is for staff to always be wearing hair restraints in the kitchen. The DM further stated it was important for hair to be completely covered to ensure no hair gets in the food being…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-09 · tag F0585 — failed to handle grievances — patternHonor 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 interviews and record reviews the facility failed to ensure the residents had the right to voice grievances to 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 2 of 8 residents (Residents #1 and #2) reviewed for grievances. On 11/9/2024 Resident #1 made a grievance to Medication Aide A (MA A) which she did not document or report to the DON. The grievance alleged he did not receive medications on 11/8/2024. On 11/19/2024 Resident #2 made a grievance to Case Manager D (CM D) which she did not document or report to the DON. Resident #2 alleged he was left at the doctor's office for hours without return home transportation. These failures could place residents at risk for harm by leaving residents with frustration and demoralization. The findings included: 1. A record review of Resident #1's admission record dated 5/7/2025 revealed…
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 · D2025-05-09 · 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 ensure that residents received treatments and care in accordance with professional standards of practice and the residents' choices for 1 of 8 residents (Resident #3) reviewed for quality of care. Resident #3 had a cardiology appointment on 11/13/2024, for an echocardiogram (an exam which uses sound waves to make pictures of the heart), and the facility failed to attempt to provide a chaperone to the appointment when her representative was late; subsequently Resident #3 missed her appointment. This failure could place residents at risk for decreased quality of care due to delayed health status reports to the physicians. The findings included: A record review of Resident #3's admission record dated 5/7/2025 revealed Resident #3 was a [AGE] year-old female admitted [DATE] with diagnoses which included heart failure, cardiomegaly (enlarged heart), and need for assistance with personal care. A record review of Resident #3's physicians order 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 before2025-02-15 · 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 review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #3) reviewed for resident records. The facility failed to ensure the wound administration records (WAR) for Resident #3 accurately reflected the wound care that was provided to her sacrum (large triangular bone at base of the spine) wound and ischium (the curved bone forming the base of the pelvis) wound on 5 different treatment days in November and December 2024. This failure could put residents at risk of inaccurate documentation. The findings were: Record review of Resident #3's admission Record (face sheet), dated 02/12/2025, revealed she was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (kidney failure), high blood pressure, diabetes (long-term condition in which the blood sugar level is too high which can result in damage to many of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · F2024-10-31 · tag F0837 — widespreadEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
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 the governing body appointed an administrator who was licensed by the State, where licensing is required; responsible for management of the facility; and reports to and is accountable to the governing body for 1 of 1 facility reviewed for the governing body, in that: The governing body failed to appoint an administrator who was responsible for the management of the facility. This deficient practice could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents. The findings include: During an interview on 10/28/2024 at 9:05 AM, OM L introduced himself to the survey team as the OM of the facility and stated he did not have an administrator license but was in the process of obtaining one. The facility had an administrator who did not work at the facility full-time. He was at the facility full-time and was responsible for the daily management of the facility. During an interview on 10/30/2024 at 12:35 PM, the Administrator stated she assumed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-31 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 maintain medical records on each resident that were complete and accurately documented for 1 (Resident #67) of 6 residents reviewed for clinical records. The facility failed to ensure CNA F documented oral hygiene care that was offered, performed or refused by Resident #67 on 10/4/2024, 10/7/2024, 10/11/2024, 10/15/2024, 10/25/2024, 10/28/2024 and 10/29/2024. This deficient practice could place residents at risk of improper care due to inaccurate medical records. The findings were: Record review of Resident #67's face sheet, dated 10/28/2024, revealed a [AGE] year-old female with an admission date of 10/17/2022, and diagnoses which included: Dysphagia (trouble swallowing) following Cerebral Infarction (stroke resulting from blood flow to brain being blocked); Non-Traumatic Intracerebral Hemorrhage in Hemisphere (bleeding in the brain); Seizures (uncontrolled jerking, loss of consciousness, blank stares or other symptoms caused by abnormal electrical…
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 · E2024-10-31 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 15 residents (Residents #67, #49 and #6) reviewed for infection control, in that: 1. While providing incontinent care for Resident #67, CNA D did not change her gloves or wash her hands after touching the privacy curtain before starting to provide care. 2. While observing LVN I perform an accu-check test on Resident #49, a used lancet (a sharp pointed medical instrument used to puncture the skin to obtain a small amount of blood for testing) was observed on Resident #49's bedside table that was parallel next to her bed, within her reach and lying next to some candy wrappers. 3. While preparing to administer eye drops to Resident #6, MA J took off the lid to the eye dropper, obtained a tissue from the box next to 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 · D2024-10-31 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 6 residents (Resident # 67) observed for resident rights. The facility failed to ensure CNA F sat down while feeding Resident #67 in her room on 10/29/2024. This failure could place residents at risk of not being treated with dignity and respect. Findings included: Record review of Resident #67's face sheet dated 10/28/2024, revealed a [AGE] year-old female with an admission date of 10/17/2022, and diagnoses which included: Dysphagia (difficulty swallowing) following cerebral infarction (stroke); and gastrostomy status (has g-tube to bring nutrition directly into the stomach) Record review of Resident #67's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 4, indicating severe cognitive impairment. Further review under Section GG - Functional Abilities and Goals, shows Resident #67 was assessed as needing Supervision or touching assistance for eating.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-31 · 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 have a right to personal privacy for 1 of 5 residents (Resident #351) reviewed for privacy, in that: 1. LVN A and LVN B failed to provide privacy to Resident #351 while providing wound care by not closing completely Resident #351's privacy curtain. 2. LVN A failed to protect Resident #351's record by not locking the screen of her laptop. These deficient practices could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #351's face sheet, dated 10/31/2024, reflected an admission date of 06/28/2023 and, a readmission date of 10/02/2024, with diagnoses which included: Osteomyelitis (infection of bone), Hydronephrosis (kidney swelling), Colostomy status (opening in the large intestine created by surgery), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Chronic kidney disease (gradual loss of kidney function), Type 2 diabetes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-31 · tag F0641 — isolatedEnsure 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 of 7 residents (Resident #48) whose assessments were reviewed, in that: Resident #48's quarterly MDS assessment incorrectly documented the resident as not receiving an anticoagulant medication. This failure could place residents at-risk for inadequate care due to inaccurate assessments. The findings were: 1. Record review of Resident #48's face sheet, dated 10/28/2024, revealed an admission date of 05/06/2023 and, a readmission date of 01/30/2024 with diagnoses that included: Cerebral infarction (stroke), Deep vein thrombosis (blood clot). Record review of Resident #48's Physician orders and Medication administration record for October 2024 revealed an order for: Eliquis (an anticoagulant) Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for DVT [deep vein thrombosis right popliteal (back of the knee) vein]. Resident #48 had received Eliquis in the month 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 · D2024-10-31 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 6 residents (Resident #67) reviewed for hygiene, in that. The facility failed to ensure Resident #67 received a shower or bath as scheduled on 10/12/2024 and 10/14/2024. This deficient practice could place residents who were dependent on staff for ADL care at risk for loss of dignity, and/or a diminished quality of life. The findings were: Record review of Resident #67's face sheet, dated 10/28/2024, revealed a [AGE] year-old female with an admission date of 10/17/2022, and diagnoses which included: Dysphagia (trouble swallowing) following Cerebral Infarction (stroke resulting from blood flow to brain being blocked); Seizures (uncontrolled jerking, loss of consciousness, blank stares or other symptoms caused by abnormal electrical activity in brain); Contracture (fixed tightening of 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 · Dcited before2024-10-31 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to store, label and date two containers of milk properly in the walk-in cooler. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 10/28/2024 at 10:52 AM in the walk-in cooler revealed a one-gallon container of whole milk and a one-gallon container of Lactose-Free whole milk. The container of whole milk was opened, there was approximately 1 cup remaining in the container, and labeled 10/25. The container of Lactose-Free milk was opened, there was approximately one quart of milk remaining in the container and labeled 10/15. During an interview on 10/28/2024 at 10:53 AM, the DS stated the dates on the containers of milk were the dates they were received by the facility and stored in the cooler. They did not indicate the date they…
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 · E2023-09-15 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident, for 2 of 9 residents (Residents #187 and #81) reviewed for baseline care plan, in that: 1. Resident #187's baseline care plan did not include the resident's code status, diet order, need for care of multiple wound sites, need for sternal precautions due to surgery, or need for isolation due to an infectious disease diagnosis. 2. Resident #81's baseline care plan did not include the resident's need for a gluten free diet due to a diagnosis of celiac disease. This deficient practice could affect all residents who require staff assistance and interventions to maintain the highest practicable level of health and well-being. The findings were: 1. Record review of Resident #187's face sheet, dated 09/12/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including:…
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 · D2023-09-15 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 residents' right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 18 residents (Resident #6) reviewed for advanced directives, in that: Resident #6's OOH-DNR form was improperly executed via family member's signature, not Resident #6. This deficient practice could place residents at-risk of having their end of life wishes dishonored and of having CPR performed against their will. The findings were: Record review of Resident #6's face sheet, dated [DATE], revealed an [AGE] year-old female admitted to facility on [DATE] with diagnosis that included: [Insomnia] is a sleep disorder in which you may have trouble falling asleep, staying asleep, or getting good quality sleep, [Chronic obstructive pulmonary disease] a group of diseases that cause airflow blockage and breathing-related problems, and [Alzheimer's Disease] a progressive…
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 before2023-09-15 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 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 conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity, not less than once every 12 months, excluding readmissions in which there is no significant change in the resident's physical or mental condition for 1 of 18 residents (Resident #34) reviewed for comprehensive assessments and timing, in that: The facility failed to ensure an MDS Annual Assessment for Resident #34 was completed every 12 months. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings include: Record Review of Resident #34's face sheet, dated 9/14/23, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: [Atrial fibrillation] is an irregular and often very rapid heart rhythm, [diabetes mellitus] is a disease in which the body's ability to produce or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-15 · tag F0770 — failed to provide lab services — isolatedProvide 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 observations, interviews, and record reviews the facility failed to provide or obtain laboratory services for 1 of 18 residents (Resident #18) reviewed for laboratory services, in that: Resident #18's Depakote levels were not checked every three months while prescribed Depakote as ordered by Resident #18's physician. This failure placed residents at risk for not having lab services completed resulting in delayed treatment or residents' needs not being met. The findings included: Record review of Resident #18's face sheet dated 09/14/2023 revealed an admission date of 07/28/2018 with diagnoses which included dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), heart failure, hypertension (high blood pressure), chronic kidney disease, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-15 · 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 maintain medical records on each resident that were complete and accurately documented for 1 (Resident #187) of 29 residents reviewed, in that: Resident #187's medical diagnoses were not reflected on her face sheet. This deficient practice could place residents at risk of improper care due to inaccurate medical records. The findings were: Record review of Resident #187's face sheet, dated 09/12/2023, revealed the resident was admitted to the facility on [DATE]. Further review revealed a single diagnosis was listed: Encounter for Surgical Aftercare Following Surgery on the Circulatory System. Record review of Resident #187's clinical record revealed the resident's admission MDS had not yet been completed due to her status of having been newly admitted to the facility. Record review of Resident #187's care plan as of 09/15/2023, revealed a focus, Anticoagulant therapy (Apixaban) [related to]: post-surgical [coronary artery bypass surgery] and an…
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 · C2024-10-31 · tag F0814 — failed to dispose of garbage properly — widespreadDispose 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 failed a to dispose of garbage and refuse properly for 2 of 2 dumpsters (dumpsters #1 and #2) reviewed for disposal of garbage. 1. The facility failed to ensure the waste in dumpster #1 was removed to allow the top lid to close 2. The facility failed to ensure dumpster #2 had a drainage plug and the right door was completely shut These deficient practices could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings were: 1. Observation on 10/30/2024 at 11:59 AM revealed there was overflowing trash at the top of the dumpster, preventing the lid from closing and leaving a gap approximately 18 in length. There was a piece of cardboard approximately 2' x 3' on the ground in front of dumpster #1, and there were flies circulating between the two dumpsters. During an interview on 10/30/2024 at 12:00 PM, the DS stated the top lid should have been closed, the facility's trash was supposed to be picked up daily, and it did not appear the trash had been picked up recently. She told…
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 THE ENSIGN GROUP — 342 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 | 4 of 5 | 3.2 | +0.8 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 1 of 5 | 2.7 | -1.7 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| AZIZ, WESAM | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 04/14/2025 |
| BURNAM, SOON | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | since 08/19/2019 |
| WINTERS, TESHA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/14/2025 |
| ABBOTT, SWATI | Individual | CORPORATE DIRECTOR | since 01/01/2020 |
| AGWUNOBI, JOHN | Individual | CORPORATE DIRECTOR | since 01/01/2023 |
| BLOUIN, ANN | Individual | CORPORATE DIRECTOR | since 11/28/2018 |
| CHRISTENSEN, CHRISTOPHER | Individual | CORPORATE DIRECTOR | since 11/01/2014 |
| PARKINSON, MARK | Individual | CORPORATE DIRECTOR | since 10/01/2024 |
| SHAW, DAREN | Individual | CORPORATE DIRECTOR | since 03/01/2012 |
| SMITH, BARRY | Individual | CORPORATE DIRECTOR | since 06/01/2014 |
| ASHTON, ANDREW | Individual | CORPORATE OFFICER | since 08/19/2019 |
| BURTON, SPENCER | Individual | CORPORATE OFFICER | since 05/30/2015 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | since 11/01/2019 |
| PORT, BARRY | Individual | CORPORATE OFFICER | since 11/01/2019 |
| SNAPPER, SUZANNE | Individual | CORPORATE OFFICER | since 09/07/1973 |
| WITTEKIND, BEVERLY | Individual | CORPORATE OFFICER | since 09/29/2008 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | since 11/01/2019 |
| OLMSTEAD HEALTH HOLDINGS LLC | Organization | ADP OF THE SNF | since 01/01/2022 |
| STANDARD BEARER HEALTHCARE OP, LP | Organization | ADP OF THE SNF | since 01/01/2022 |
| THE ENSIGN GROUP INC | Organization | ADP OF THE SNF | since 01/01/2022 |
CMS files one row per role, so the 24 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
4 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.
About 70% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.0M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 676250. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-30, 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.