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Sage Park San Antonio

855 E Basse Rd, San Antonio, TX 78209 · For profit - Partnership · 46 certified beds · (210) 930-1040 Medicare only — no Medicaid

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1 immediate-jeopardy citation$121,976 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $121,976 in federal fines (most recent 2024-05-04)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 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 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
555 E Basse Rd · (210) 546-1430 · Call to confirm hours
Pharmacy
999 E Basse Rd Ste 150 · (210) 822-0270 · Call to confirm hours
Grocery
999 E Basse Rd · (210) 822-0270 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents who lose too much weight0.0%3.0%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder5.6%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms12.1%2.4%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%3.3%3.3%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication16.7%18.0%18.9%better
Long-stay residents with pressure ulcers1.0%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control17.1%13.4%21.2%better
Short-stay residents who newly got an antipsychotic medication0.7%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine73.1%88.0%79.4%typical
Short-stay residents rehospitalized after admission26.0%25.7%22.6%worse
Short-stay residents with an outpatient ER visit7.6%12.3%12.0%better

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

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

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.

68.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 283 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

68.2%U.S. median 51.5%
Got home and stayed home
9.5%U.S. median 10.7%
Went back to hospital
59.4%U.S. median 56.6%
Met the expected recovery
0.86U.S. median 0.31
Therapy hours / resident / day
0.29hours / resident / day
Physical therapy
0.39hours / resident / day
Occupational therapy
0.18hours / resident / day
Speech therapy

Met the expected recovery: 59.4% 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 101 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 0.86 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF68.2%CMS range 62.4–73.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.5%CMS range 6.9–12.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge59.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge54.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge44.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting97.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge93.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.1%CMS range 4.0–8.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.99
RN hours/ resident / day
1.21
LPN hours/ resident / day
2.11
Aide hours/ resident / day
4.32
Total nurse hours/ resident / day
0.87
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 46 beds and averages 27.8 residents a day — about 60% occupied, or roughly 18 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 4.32 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.99 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 3.60 hrs/resident/day on weekends vs 4.61 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.03 to 0.87 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

11
deficiencies at the latest standard inspection (2026-01-09)
9
at the previous standard inspection (2024-10-11)

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

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2024-05-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for respiratory care, in that: 1. The facility failed to monitor Resident #1 to ensure she was connected to continuous oxygen in accordance with her physician's order. 2. The facility failed to accurately document Resident #1's oxygen saturation levels when they were discovered to be in the 60s as a result of not being connected to continuous oxygen in accordance with her physician's order. 3. The facility failed to accurately document Resident #1's change of condition in her progress notes upon discovering Resident #1 was not connected to continuous oxygen in accordance with her physician's order. 4. The facility failed to ensure Resident #1 was connected to an oxygen concentrator with a functioning humidifier upon being transferred to a different location within the facility. These failures resulted in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-09 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the 1 of 1 kitchen failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. 1-The facility failed to have four kitchen staff complete their food handler certificates (Cook-I, DA-J, DA-K, DA-L) These failures could place residents at risk for food borne illness. The findings included: During an interview on 1/8/26 at 1:10pm with the Executive Chef she stated not having the four identified staff (Cook-I, DA-J,DAK,DA-L) completed their Food Handlers Certificates was an oversight. Record review of the Dietary Staff's Food Handler Certificates revealed four kitchen staff had not completed their Food Handler Certificates (Cook-I, DA-J, DA-K, and DA-L) Review of the Texas Food Code revealed the following: The Texas Department of State Health Services (TXDSHS) requires that all food employees must successfully complete an accredited food handler training course within 60 days of employment The training courses teach employees about food safety, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the 1 of 1 kitchen failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. 1. The facility failed to clean two wall vents which measured approximately 4x2 ft which were located across from the kitchen's freezer. 2. The facility failed to clean a 3x3 ft ceiling vent in the dry storage room. 3. The facility failed to clean a 3x3 ft ceiling vent located at the entrance to the dish room. 4. The facility failed to maintain proper hair restraints on two kitchen employees (Cook-G and DA-H) 5. The facility failed to maintain the required dish machine rinse temperature, and only reached 110 degrees Fahrenheit. 6.-The facility failed to clean the top surface of the dish machine in the kitchen's pantry room. 7.-The facility failed to repair the brown stained ceiling markings around the sprinkler head in the kitchen's pantry room. These failures could place residents at risk for food borne illness. The findings included: 1-Observation on 1/6/26 from…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to establish and maintain, an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 4 of 29 residents (Residents #38, #39, #8 and #3) reviewed for incontinent care. 1. facility failed to ensure LVN C sanitized the blood pressure cuff when she used it between two residents (Residents #38 and #39) during medication pass. 2. The facility failed to ensure CNA D discarded her soiled gloves, sanitized her hands and put clean gloves on when she placed Resident #8's soiled brief in the trash can and continued to place clean items onto the resident. 3. The facility failed to ensure CNA D retracted Resident #3's foreskin on his penis and to clean his buttock and anal area completely. These deficient practices could place residents at risk of cross contamination and infections.The findings included:…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-09 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 2 of 27 resident rooms on (rooms [ROOM NUMBERS]) and the beauty salon and laundry room reviewed for environmental concerns.1-The facility failed to replace an overhead bathroom sink light cover in room [ROOM NUMBER].2-The facility failed to replace an overhead bathroom sink light cover in room [ROOM NUMBER].3-The facility failed to clean an 18 x 18 ceiling air vent in the beauty salon.4-The facility failed to clean an 18 x 18 ceiling air vent in the laundry room. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.The findings included: Observations during rounds on 1/8/26 from 12:15pm to 12:25pm with the Administrator and Environmental Services Director revealed the following:a-In resident room [ROOM NUMBER] there was a missing…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-09 · tag F0641 — isolated
    Ensure 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 observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 16 residents (Resident #8) reviewed for accurate MDS assessments.The Facility failed to ensure Resident #8's fall status was accurately reflected on her quarterly MDS assessment, dated 11/14/2025.This deficient practice could place residents at risk of missed or inaccurate care. The findings include: Record review of Resident #8's electronic face sheet, dated 01/06/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: hypertensive heart disease with heart failure (long term condition that develops due to unmanaged high blood pressure and can lead to heart failure, thickening of the heart muscle and other serious health issues), anxiety disorders (a group of mental disorders characterized by significant and uncontrollable feelings of nervousness and fear that interferes with daily life), and pain (physical…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, 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 includes 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 #8) reviewed for comprehensive person-centered care plans.The facility failed to ensure a care plan was developed to address Resident #8 as a fall risk and include interventions to prevent falls. This deficient practice could place residents at risk for falls and could result in injury. The findings include: Record review of Resident #8's electronic face sheet dated 01/06/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: hypertensive heart disease with heart failure (long term condition that develops due to unmanaged high blood pressure and could lead to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 resident of 2 residents (Resident #3) reviewed for incontinent care. CNA D failed to pull back Resident #3's foreskin to clean his penis during incontinent care. This deficient practice could place residents risk of urinary tract infections (bacteria in the urine) or skin breakdown. The findings include: Record review of Resident #3's electronic face sheet, dated 01/07/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: acute respiratory failure with hypoxia (severe impairment of gas exchange in the lungs, leading to low oxygen levels in the blood), muscle weakness (loss of muscle strength), anemia (not having enough health red blood cells to carry oxygen to the body's tissues), atrial fibrillation…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 5 residents (Residents #14 and #15) reviewed for oxygen therapy. The facility failed to replace a dirty and worn oxygen filter in Resident #14's oxygen concentrator, humidifier bottle was not changed and NC tubing was not bagged when not in use. 2. The facility failed to replace a dirty and dusty oxygen filter in Resident #15's oxygen concentrator, nebulizer mask was not bagged when not in use. These deficient practices could places residents at risk of respiratory infection and difficulty breathing.The findings included: Record review of Resident #14's electronic face sheet, dated 01/07/2026, reflected a [AGE] year-old female who was admitted to the facility on [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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-09 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and record reviews, the facility failed 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 (Medication Cart B and C Halls) of 2 medication carts reviewed for expired medications.The facility failed to ensure the Medication Cart for B and C Halls did not contain an expired bottle of Atropine 1% drops.This deficient practice could place residents at risk to receive expired medication with less effective results.Observation on 01/08/2026 at 08:20 am accompanied by LVN F when checking the Medication Cart for B and C Halls, revealed a plastic bottle of Atropine 1%, with an expiration date of 08/29/2025 was found on the cart.During an interview on 01/08/2026 at 3:05 pm, LVN F stated she would usually check the medication cart for expired medications when she worked. She did not know how the expired bottle of Atropine was not removed from the cart sooner. She stated the effectiveness of the medication 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-09 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record reviews, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for and 1 of 1 treatment cart (Treatment Cart) reviewed for medication storage. The facility failed to ensure RN A and the ADON did not leave the treatment cart unlocked when they went to perform a treatment on a resident. These deficient practices could place residents at risk of misappropriation of treatment medications and supplies. The findings were: Observation on 01/07/2026 at 3:20 pm, revealed RN A and the ADON performed wound care for Resident #3 revealed RN A took the wound care treatment and supplies into the residents room without securing the treatment cart…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Ecited before2024-10-11 · tag F0641 — pattern
    Ensure 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 observation, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 5 of 12 residents (Residents #15, #18, #5, #1, and #20) whose assessments were reviewed, in that: 1. Resident #15 had falls on 8/30/2024 and 9/5/2024 but Resident #15's Quarterly MDS dated [DATE] revealed falls after admission was not coded for falls after admissioon or readmission. 2. Resident #18 had been using oxygen per nasal canula at 2 liters continuously since admission, but the admission MDS dated [DATE] was not coded for oxygen use. 3. Resident #5 had a fall on 9/8/2021 but Resident #5's QMDS dated [DATE] revealed falls after admission was not coded for falls after admission or readmission. 4. Resident #1 had been receiving hospice care since 11/30/2022, but Resident #1's quarterly MDS, dated [DATE], indicated regarding the question of if or not resident was receiving hospice care, the answer was marked as no. 5. Resident #20 had deep tissue injury to his left…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-11 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: During observation of the kitchen on 10/08/2024 at 10:01AM with the DM revealed: 1. There was a bag of kernel corn left open in the walk-in freezer. 2. There was container with slices of turkey not labeled or dated in the walk-in cooler. 3. There was a bag with two rolls left open in the dry storage room. 4. There was a box of oatmeal with the top off in the dry storage room. 5. There were six containers of seasoning not closed in the dry storage room. 6. There were two backpacks stored on a shelf next to food in the dry storage room. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation and interview on 10/08/2024 at 10:01AM revealed there was a bag of kernel corn in a box left open on a shelf in the walk-in freezer. The DM stated they should not be left open in the freezer…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · tag F0655 — isolated
    Create 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 observation, interview, and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 5 residents reviewed for new admissions. (Resident #78) The facility failed to develop Resident #78's baseline care plan dated 10/01/2024 regarding the resident's physician order dated 10/01/2024 for colostomy care within 48 hours of admission on [DATE]. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #78's face sheet, dated 10/10/2024, reflected the resident was [AGE] years old female and admitted to the facility on [DATE] with diagnosis of laceration of sigmoid colon (injury that can occur after penetrating trauma to the abdomen), type 2 diabetes mellitus (not properly use insulin to process sugar for energy), colostomy status…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 12 Residents (Resident #1) whose records were reviewed for care plan revision/timing, in that: Resident #1's care plan dated 08/25/2022 was not updated after her quarterly MDS assessment, dated 09/05/2024, reflected she was always incontinence to bowel. These deficient practices could affect any resident and contribute to Residents not receiving the care and services they needed. The findings included: Record review of Resident #1's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old female and admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the diagnosis of atherosclerotic hear disease of native coronary artery without angina pectoris (heart disease caused by the buildup of plaque in the arteries), cerebral infarction (disrupted blood flow to the brain), epilepsy (chronic brain disorder that causes recuring…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and safe environment to prevent accidents for 1 of 12 residents (Residents #20) reviewed for environment. The facility failed on 10/08/2024 when there was one used disposable razor found on the sink faucet of Resident # 20's bathroom. This deficient practice cause infection or other physical injuries to residents and even staff. Findings included: Record review of Resident #20's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old male and admitted to the facility 08/21/2024 and re-admitted to the facility on [DATE] with diagnosis of acute respiratory failure (lung cannot release enough oxygen into blood), anemia (not have enough red blood cells), type 2 diabetes mellitus (not properly use insulin to process sugar for energy), pressure ulcer of sacral region-stage 3 (bed sore to buttock area), hypertension (high blood pressure), and spinal stenosis (narrowing 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-11 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 1 of 3 medication carts (A and B hall nursing cart) reviewed for pharmacy services. There was one medication (Benadryl itching stopping gel topical for skin use only) expired on 05/2021 found inside A and B hall nursing cart on 10/9/2024. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: Observation on 10/09/2024 at 1:54 p.m. revealed one gel of Benadryl itching stopping gel topical for skin use only was found inside A and B hall nursing cart, and it was expired 05/2021. Interview on 10/09/2024 at 2:00 p.m. with ADON acknowledged one gel of Benadryl itching stopping gel topical for skin use only was found inside A and B hall nursing cart, and it was expired 05/2021. Further interview with the ADON said she did not…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-11 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys to 1 of 12 residents (Resident #9) reviewed for medications at the bedside. Resident #9's ear wax remove kit was left unattended and unsecured on the nightstand at the resident's bedside on 10/08/2024. These failures could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards, and not receiving therapeutic effects. The findings included: Record review of Resident #9's face sheet, dated 10/10/2024, reflected the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses included: pneumonia (lung infection), hypomagnesemia (low magnesium in the blood), cerebral vascular disease (problems with blood flow to the brain), heart failure (heart unable to pump enough blood), dementia (decline in…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #20) of 12 residents reviewed for accuracy and completeness of clinical records. Wound care nurse RN-C documented on the skin evaluation, dated 08/21/2024 Resident #20's deep tissue injury was to the resident's right heel, when the resident had deep tissue injury to his left heel on 10/10/2024. This failure placed facility residents at risk for lack of wound care or incorrect wound care due to misinformation by incomplete and inaccurate medical record. Findings included: Record review of Resident #20's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old male and admitted to the facility 08/21/2024 and re-admitted to the facility on [DATE] with diagnosis of acute respiratory failure (lung cannot release enough oxygen into blood), anemia (not have enough…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 resident (Residents #1) of 12 residents reviewed for infection control. The facility failed on 10/08/2024 to discard in a red plastic bag, sealed, and placed in biohazard storage a Suction tube Yankauer (oral suction tool used in medical procedure) that was found opened, covered in the plastic bag, connected to the suction machine and was on Resident #1's nightstand. The Yankauer appeared to be dirty with brown colored residual. These deficient practices affect residents who require suction and could place residents at risk for cross contamination and infections. The findings included: Record review of Resident #1's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old female and admitted to the facility on [DATE] and…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-09-08 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Main Kitchen), in that: 1. The facility failed to ensure an items in the walk-in refrigerator and dry storage areas were dated and or discarded correctly 2. The facility failed to ensure equipment used to cook were properly and thoroughly cleaned. These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness. The findings included: 1. During an observation and interview on 09/06/2023 beginning at 11:21 a.m., revealed in the walk-in refrigerator a 5 lb. bag of opened mozzarella with no received or opened date; two each of 1 lb. butter with no received date; five each of 1 lb. [brand name] sliced Monterey jack cheese with no received dates; three each of 5 lb. shredded mild cheddar cheese with no received date; a 5 lb. shredded Monterey [NAME] cheese with no received date, seven each of 1 lb. [brand name] mozzarella cheese with no received…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-08 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 2 isolation rooms and 3 of 7 residents (Resident #4, #78 and, #130) reviewed for infection control, in that: 1. Resident #4's room had personal protective equipment on the door but no sign to indicate the type of isolation the resident was under. 2. CNA B failed to wash or sanitize her hands or change her gloves after touching the privacy curtain and before starting perineal care. 3. RN C failed to wash or sanitize her hands and change gloves after cleaning a wound. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: 1. Record review of Resident #4's face sheet, dated 09/07/2023, revealed an admission date of 02/23/2023 and, a readmission date of 07/22/2023, with diagnoses which included: Hypertension(High…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-08 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 1 shower room observed for environment, in that: The facility failed to ensure potential hazards were locked up in the shower room. This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment. The findings included: Observation on 09/05/23 11:00 a.m. revealed the shower room's door was open. A closet seen in the room had a lock but the lock was opened as well. Inside the closet, two bottle of peroxide multi surface cleanser and disinfectant were observed. The bottles had precautionary statements hazards to humans and domestic animals on them. During an interview on 09/05/2023 at 11:05 a.m. with the DON, she confirmed the bottles were in the closet and both the closet and room's doors were open. The DON confirmed the bottles had precautionary statement and confirmed she had residents with dementia who self propel who could be put at risk by accessing the bottles. 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-08 · tag F0944 — pattern
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 5 of 18 employees (CNA E, CNA F, CNA H, CNA J, LVN K, and RN M) reviewed for training, in that: The facility failed to ensure CNA E, CNA F, CNA H, CNA J, LVN K, and RN M completed QAPI training within the last year. These failures could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: 1. Record review of Staff Roster, undated, revealed CNA F was hired on 12/14/2021 Record review of CNA F's training history revealed CNA F had not completed QAPI training in the last year. 2. Record review of Staff Roster, undated, revealed the CNA H was hired on 01/18/2022 Record review of CNA H's training history revealed CNA H had not completed QAPI training in the last year. 3. Record review of Staff Roster, undated, revealed CNA J was hired on 12/28/2021 Record review of CNA J's training history 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-08 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 resident (Residents #121) reviewed for care plans, in that: The facility failed to ensure Resident #121 Full code status was care planned. This deficient practice place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: Record review of Resident #121's face sheet, dated 09/08/2023, revealed the resident was admitted on [DATE] with diagnoses that included: chronic kidney disease, adult failure to thrive, and severe protein-calorie malnutrition. Record review of Resident #121's Quarterly MDS assessment, dated 08/01/2023,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-08 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 or 2 meals (lunch) reviewed for food meeting residents' needs, in that: The facility failed to ensure the pureed mashed potatoes and pureed chicken cutlet was a pudding consistency as required for food served to residents who received a pureed diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to dissatisfaction, poor intake, choking, and/or weight loss. The findings included: Record review of posted menu, dated 09/06/2023, revealed the menu for the lunch service was Chicken Cutlet with pasta, and Garlic Mashed Potatoes [ .] During an observation and interview on 09/06/2023 beginning at 11:07 a.m., revealed the pureed chicken cutlet was too thick in the serving dish after [NAME] Q had just made it. [NAME] R walked over to [NAME] Q and instructed her to puree the chicken more consistently. The DM stated she was told the pureed items were supposed to be the consistency of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2026-01-09 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose 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 to dispose of garbage and refuse properly for 2 of 2 Dumpsters (Dumpsters #1 and #2) reviewed for garbage and refuse disposal. The facility failed to ensure Dumpster #1 and Dumpster #2 had lids that were completely closed This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings included: Observation on 01/6/26 at 10:00 am revealed Dumpster #1 and Dumpster #2 both had lids which measured approximately 3x5 ft that were not secured to the dumpster basin due to overflowing garbage inside the bin. There were also two bags of garbage and a pile of cooked noodles laying on the ground beside Dumpster #2. Interview on 1/6/26 at 10:05am with the Clinical Specialist who stated he was aware of the garbage lids needing to be secure to the garbage bins to prevent rodent infestation. The Clinical Specialist stated that the facility's garbage was to be picked up later in the day but was unsure of the exact time of pick up. Record review of the facility's…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$121,976 in federal fines across 1 penalty.

  • $121,976 — penalty dated 2024-05-04

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 / managerTypeRoleShareSince
S-H FORTY-NINE OPCO VENTURES LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/29/2014
CP OPCO VENTURES VI LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/18/2017
SHP REIT I LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/18/2017
SHP REIT I TRS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/18/2017
WEISER, TIFFANYIndividualW-2 MANAGING EMPLOYEEsince 04/07/2021
SPRAGINS, ALANIndividualCORPORATE OFFICERsince 06/01/2018
WASHBURN, ALEXANDERIndividualCORPORATE OFFICERsince 06/01/2018
JUNIPER MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2021

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.

$8.7M
Net patient revenuemost recent cost report
-10.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 0%Medicare 17%Other / private 83%

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

$314per resident / day
operating cost
$9,532per month
≈ monthly operating cost
$284per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX

Paying with Medicaid

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Texas Medicaid page for homes that do.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675542. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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