San Pedro Manor
515 W Ashby Pl, San Antonio, TX 78212 · Government - Hospital district · 150 certified beds · (210) 732-5181 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- 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 (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $24,285 in federal fines (most recent 2024-06-27)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 1 to 4 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 | 9.2% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.2% | 3.0% | 5.4% | typical |
| 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 | 0.6% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.6% | 2.4% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.3% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 25.7% | 14.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 16.5% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.2% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 12.9% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.0% | 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 | 98.6% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 12.9% | 25.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 19.5% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.69 | 2.17 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.89 | 2.06 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 58.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 36 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 0.72 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 6.8–15.8 | 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 | 58.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 41.7% | 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 | 61.1% | 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 | 89.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.1% | 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 | 0.0% | 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 | 7.1%CMS range 3.8–12.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 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 150 beds and averages 96.8 residents a day — about 65% occupied, or roughly 53 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.67 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.24 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 3.23 hrs/resident/day on weekends vs 3.86 on weekdays — 16% thinner on weekends. RN hours go from 0.34 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-05-17 · 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 interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents and supervision. The facility failed to prevent Resident #1 from eloping on 12/04/2023. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 12/4/2023 and ended on 12/22/2023. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings were: Record review of Resident #1's face sheet, dated 05/14/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: acute kidney failure (occurs when the kidneys suddenly become unable to filter waste products from the blood), chronic obstructive pulmonary disease (a common lung disease causing restricted airflow 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.
- Actual harm · Gcited before2024-06-27 · 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 and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #40) reviewed for accidents. The transportation driver failed to ensure Resident #40 was safely transferred onto the transportation van on 06/21/24 when he was picked up for dialysis. The resident sprained his foot when it got caught in the van gap where the ramp met the van. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings included: Record review of Resident #40's MDS, dated [DATE], reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included end stage renal disease (kidney failure), diabetes, osteoporosis, stroke, and seizure disorder. The MDS further Resident #40 had a BIMS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consult with the resident's physician and representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 8 residents (Resident #1) reviewed for resident rights. The facility failed to notify Resident #1's representative when staff reported a skin tear . This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. The findings included: Record review of Resident #1's face sheet dated 4/28/26 revealed a [AGE] year-old male admitted to the facility on [DATE] and with diagnoses that included anxiety disorder ( persistent, excessive, and uncontrollable worry or fear that interferes with daily life) , Hypertension, (high blood pressure, is a chronic condition where the force of blood against artery walls is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 resident (Residents #12 and #92 ) reviewed for incontinent care, in that: 1.While providing incontinent care, CNA G made multiple passes with the same wipe while cleaning Resident #12's buttocks. 2. While providing incontinent care for Resident #92, CNA E did not separate Resident #92's labias to clean the meatus (urinary opening) This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: 1.Record review of Resident #12's face sheet, dated 08/07/2025, revealed an admission date of 04/25/2024, and, a readmission date of 07/29/2025, with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood) , Dysphagia (difficulty swallowing), Hemiplegia…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-08 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 prepare and provide food and drink that was palatable, attractive, and at a safe and appetizing temperature, for 3 of 29 residents (Resident #6, #43, and #93) reviewed for palatable and appetizing food, in that: 1. The facility served Resident #6 meals that were cold. 2. The facility served Resident #43 meals that were cold 3. The facility served Resident #93 meals that were cold. These failures could place residents at risk for a diminished quality of life by not receiving food and drink that is palatable, attractive, and at a safe and appetizing temperature. The findings included: 1. A record review of Resident #6's face sheet dated 08/05/25 revealed the latest admission date of 3/26/25 for a 54- year -old male with diagnoses which included type 2 diabetes mellitus( a condition in which the body has trouble controlling blood sugar), depression disorder (a condition in which there is persistent feeling of sadness) and chronic kidney…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-08 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility in that: 1. The facility failed to replace or clean dirty overhead ceiling vents in the main kitchen area. 2. The facility failed to clean a rusty overhead ceiling vent cover in the dish room. These failures could place residents at risk for food borne illness. The findings included: Observation on 08/05/2025 from 9:20am until 9:45am of the kitchen with the Food Service Director revealed the following: a. There were 7 ceiling vents which each measured approximately 2x2 ft in the main kitchen area with visible dirt and dust particles and was stained. One of the 7 ceiling vents which was located over the standing floor freezer was not completely attached to the ceiling surface.b. There was a vent cover over the dish machine located in the dish room that had several spots of rust accumulation on the inside and outside of the vent cover. During an interview on 08/05/25 at 9:50am, 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 before2025-08-08 · 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
Based on observation, interviews, and record reviews, 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 1 of 6 residents (Resident #92 ) reviewed for infection control, in that: The facility failed to ensure CNA E used proper infection control while providing incontinent care for Resident #92. These deficient practices could place residents at-risk for infection due to improper care practices The findings include: Record review of Resident #92's face sheet, dated 08/07/2025, revealed an admission date of 01/09/2025, with diagnoses which included: Wernicke's encephalopathy (brain and memory disorder due to a lack fo vitamin B1), Dysphagia (difficulty swallowing), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure), Asthma (Long-term inflammatory disease of the airways restricting airflow). Record review 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 · D2025-08-08 · 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 6 residents (Resident #92) reviewed for privacy, in that: CNA E and CNA F did not close completely Resident #92's privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.The findings include: Record review of Resident #92's face sheet, dated 08/07/2025, revealed an admission date of 01/09/2025, with diagnoses which included: Wernicke's encephalopathy (brain and memory disorder due to a lack of vitamin B1), Dysphagia (difficulty swallowing), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure), and Asthma (Long-term inflammatory disease of the airways restricting airflow). Record review of Resident #92's Quarterly MDS assessment, dated 07/08/2025, revealed the resident had a BIMS score of 08, indicating she was moderately cognitively impaired. Resident #92 was always…
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 before2025-07-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #8) reviewed for infection control, in that: The facility failed on 07-29-2025 when CNA D failed to wear a gown while caring for Resident #8 who had a surgical chest incision and required the use of PPE., In-addition there was no EBP sign posted outside or inside the resident's room or no PPE readily available for staff or visitors use. This failure placed residents at risk of transmission of communicable diseases, a decline in health status, and hospitalization. Findings included: Record review of Resident #8's admission record dated 07/29/2025 reflected an [AGE] year-old male with an admission date of 07/24/2025. Record review of Resident #8's Medical Diagnosis tab in the EHR dated 07/29/2025, reflected…
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 before2025-07-17 · 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 observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete; and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation. Resident #1's electronic medical record did not contain complete and accurate documentation regarding whether his falls on 5/28/25 and 7/12/25 were witnessed by nursing staff or unwitnessed. This failure could result in residents' records not accurately documenting interventions, monitoring, and information provided to the interdisciplinary team as to whether a resident fall was witnessed or unwitnessed. The findings were:Record review of Resident #1's face sheet, dated 7/17/25, reflected resident was a male aged 74 admitted on [DATE] and re-admitted [DATE] and discharged [DATE] (hospital) with diagnoses that included: nontraumatic intracranial hemorrhage (residual effects from a stroke), epilepsy (seizure disorder), abnormalities of gait…
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 F0921 — failed to keep a safe, functional, sanitary building — patternMake 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 reviews the facility failed establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (3rd floor)community shower rooms in that: The 3rd floor shower room had 2 shower stalls that had drains with gobs of hair. There was brown substance under 1 shower chair, and floors were dirty with darkened areas and brown substance droppings on 1 of the shower stalls. 30 possible residents could use the 3rd floor shower room. This could affect all resident that shower in the 3rd floor shared shower and could result in infections. The Findings were: Observation on 5/6/2025 at 4:21 PM The 3rd floor shower room had 2 shower stalls that had drains with gobs of hair. There was brown substance under 1 shower chair, and floors were dirty with darkened areas and brown substance droppings on 1 of the shower…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-27 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit, prevent abuse, neglect and exploitation of residents for three of three incidents (Resident #40, Resident #36, and Resident #9) reviewed for reporting. 1. The facility failed to follow their policy to report to the State Survey Agency when Resident #40 sprained his ankle when he got his foot caught in the van ramp while being pushed by the transportation driver. 2. The facility failed to follow their policy to report to the State Survey Agency when Resident #36 was found to have ant bites on her body. 3. The facility failed to follow their policy to report to the State Survey Agency when Resident #9 was given the wrong medications on 04/22/24. These failures could place residents at risk of lacking timely reporting of incidents. Findings include: 1. Record review of the facility's, undated, policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation, or Mistreatment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · E2024-06-27 · tag F0609 — failed to report abuse allegations — patternTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse, and neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency in accordance with State law through established procedures for three (Resident #40, Resident #36, and Resident #9) of three incidents (Resident #40, Resident #36, and Resident #9) reviewed for reporting. 1. The facility failed to report to the State Survey Agency when Resident #40 sprained his ankle when he got his foot caught in the van ramp while being pushed by the transportation driver. 2. The facility failed to report to the State Survey Agency when Resident #36 was found to have ant bites on her body. 3. The facility failed to report to the State Survey Agency when Resident #9 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-27 · 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Residents # 57 and # 185) of 8 residents reviewed for infection control. Staff failed to don appropriate Personal Protective Equipment (PPE) while providing care to Resident #57, who had a colostomy, and Resident #185, who had a catheter. This failure could place residents at risk of contracting an infection from residents on Enhanced Barrier Precautions (EBP). Findings included: Record review of Resident #57's undated admission Record reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #57 had diagnoses which included spinal bifiida (birth defect causing the spinal cord to not develop), paraplegia (paralysis below the waist), and bowel impairment requiring a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-27 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 6 residents (Resident #8) reviewed for safe and functional equipment. The facility failed to ensure Resident #8's bed was in proper working condition. This failure could place residents at risk for skin tears, injury, falls and discomfort during transfers. Findings included: Record review of Resident #8's face sheet, dated 06/27/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #8's quarterly MDS, dated [DATE], reflected she had a BIMS score of 15, which indicated cognition was intact. Resident #8 had active diagnoses which included biliary cirrhosis (chronic liver disease), chronic pain syndrome, fibromyalgia (pain and tenderness all over the body). Resident #8 required the use of a wheelchair and required assistance of 2 or more helpers with bed mobility, toileting,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-27 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 effective pest control program so the facility was free of pests and rodents for 1 of 1 facility kitchen and 1 (Resident #36) of 5 residents reviewed for pest control. 1. Resident #36 repored her bed was infested with ants and she had numerous bites to her arms and legs. 2. There were multiple gnats observed in the kitchen food preparation area, storage area room, dishwasher room and floor drain This failure could place residents at risk of a decreased quality of life and cross contamination of food. Findings include: 1. Record review of Resident #36's, undated, admission Record reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 had with diagnoses that which included diabetes, stroke, and muscle wasting. Record review of Resident #36's quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. Her Functional Status reflected she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide comfortable and safe temperature levels between a range of 71 to 81 degrees Fahrenheit for one of ten residents (Resident #2) reviewed for environment. The facility failed to ensure Resident #2's room remained at a comfortable temperature. This failure could place residents at risk of experiencing decreased comfort and could affect the well-being of residents. Findings include: Record review of Resident #2's MDS, dated [DATE], reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included hypertension (high blood pressure), anxiety disorder, and chronic obstructive pulmonary disease. Observation and interview on 06/25/24 at 10:40 AM with Resident #2 revealed he was in his room sitting in his bed. The resident said his room had been hot for a while and he had let the Maintenance Assistant know but the AC in his room had not been fixed. Observation of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility to ensure a new resident was not admitted with a mental disorder, unless the state mental health authority determined, based on an independent physical and mental evaluation performed by a person or entity other then the State mental health authority prior to admission for one of six residents (Resident #63) reviewed for Preadmission Screening and Resident Review (PASRR) screening . The Social Worker failed to ensure Resident #63's PL1 was accurate with the proper metal illness diagnosis when he was admitted . This failure could place residents at risk of not receiving specialized services. Findings included: Record review of Resident #63's MDS, dated [DATE], reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included schizoaffective disorder, schizophrenia and depression. Record review of Resident #63's care plan, revised on 11/27/24, reflected the resident was at risk for impaired cognitive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident who was fed by enteral means, received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding, including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for one of four residents (Resident #19) reviewed for enteral feeding. The facility failed to ensure nursing staff provided g-tube (a tube into the stomach that delivers formula for nutrition) care for Resident #19 per physician orders. This failure could result in the spread of resident infections. Findings included: Record review of Resident #19's face sheet, dated 06/27/24, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #19's quarterly MDS, dated [DATE], reflected she had a BIMS score of 03, which indicated her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents (Resident #9) reviewed for pharmacy services. LVN A failed to administer the correct physician ordered medication (Pantoprazole Sodium Delayed Release 40 mg tablet and Tramadol HcL 50 mg tablet), and she instead administered Alprazolam Oral Tablet 0.5 mg (anti-anxiety medication), and Hydrocodone-Acetaminophen 10-325 mg (narcotic pain medication), which was another resident's medication on 04/22/24. This failure could place residents at risk for significant medication errors and jeopardize the resident health and safety. Finding included: Record review of Resident #9's face sheet, dated 06/27/24, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #9's quarterly MDS, dated [DATE], reflected she had a BIMS score of 03, which indicated his cognition was severely impaired.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-27 · 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 observation, interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, the medical record was maintained on each resident that were complete and accurately documented for 1 of 4 residents (Resident #19) records reviewed for treatment documentation. The facility failed to ensure LVN F accurately documented Resident #19's g-tube (a tube into the stomach that delivers formula for nutrition) care. This failure could affect any resident, placing them at risk of inaccurate information and resulting inappropriate care. Findings included: Record review of Resident #19's face sheet, dated 06/27/24, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #19's quarterly MDS, dated [DATE], reflected she had a BIMS score of 03, which indicated her cognition was severely impaired. She had active diagnoses which included dysphagia (difficulty swallowing)…
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 · Fcited before2024-06-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 ensure food items were kept away from potential airborne contaminants (dust and fuzz) on the ceiling vents. This failure could place residents at risk for food contamination and food-borne illness. Findings included: Observation on 06/25/24 at 8:43 AM revealed five air conditioning vents over the food preparation area in the kitchen were observed to have built-up fuzz and dust stuck to them. Interview on 06/25/24 at 11:18 AM with [NAME] revealed a couple of months ago, exact date unknown, the kitchen was remodeled. He stated he could not recall if the air vents were replaced or cleaned but that was the last time the air vents were cleaned. He stated it was the responsibility of the maintenance staff to clean the air vents. He stated he had not reported to maintenance staff that air vents needed to be cleaned. [NAME] stated 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 · Dcited before2024-05-17 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, 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 1 of 2 residents (Resident #2) reviewed for infection control, in that: CNA A did not change her gloves or wash her hands after touching Resident #2's privacy curtain, between change of gloves and, after providing incontinent care for Resident #2. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #2's face sheet, dated 05/16/2024, revealed an admission date of 01/20/2020 and, a readmission date of 09/30/2023, with diagnoses which included: Dislocation of right hip (thighbone separates from the hip bone), Chronic pain, History of urinary tract infection (infection in any part of the urinary system), Cerebellar ataxia (Lack of voluntary coordination of muscles movements originating in the cerebellum…
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 · D2024-04-02 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 4 residents (Resident #1) reviewed for medication administration. The facility failed to ensure Resident #1 received his scheduled Alprazolam Oral Tablet .5 MG in accordance with his physician's orders. This failure could place residents at risk of not receiving the therapeutic benefits of their medications. Findings included: Record review of Resident #1's electronic face sheet, not dated, indicated Resident #1 was a [AGE] year-old male originally admitted on [DATE]. Resident #1's diagnoses included: Quadriplegia, muscle weakness, myocardial infarction, schizoaffective disorder, psychotic disorder, major depress, pain, and anxiety. Record review of a significant change MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 14, which indicated Resident #1 was cognitively intact. Further review revealed Resident #1 had a PHQ9 Score…
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 · Fcited before2023-05-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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: 1. There was a bag of shredded cheese past its use-by date in the walk-in cooler. 2. There were two containers of milk that had been opened that were without labels indicating the date they had been opened. 3. The dish machine failed to reach the proper temperature during the wash cycle. 4. [NAME] C was wearing jewelry on her hand while preparing food in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 05/09/2023 at 9:00 a.m. revealed there was a bag of shredded Mozzarella cheese on a shelf in the walk-in cooler. The cheese had been removed from its original package and placed in a clear, gallon-sized, zipper-sealed bag. On the bag was hand-written, Came in 3/10, opened 3/15, exp. 4/5/23. Interview on 05/09/2023 at 9:02 a.m. with the DM revealed based…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-05-12 · 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
Based on observation and interview the facility failed to keep confidential all information contained in the resident's records, regardless of the form or storage method of the records and failed to safeguard medical record information against loss, destruction, or unauthorized use for 1 of 1 facility. Residents' medical records were stored in an unlocked room on the 3rd floor that was being remodeled. Medical record sheets were out of their files and scattered on the floor in multiple places in the room. This failure could place resident identifiable information at risk of unauthorized use. The findings were: Observation on 5/9/23 at 9:20 a.m. revealed surveyors had been placed in a conference room on the 3rd floor. There were no residents on the floor as it was being remodeled and under construction. Observation on 5/9/23 at 3:30 p.m. revealed construction workers were working on the 3rd floor and walking in the hallway. An unknown staff member was standing in the hallway waiting on the elevator. Observation on 5/10/23 at 4:34 p.m. revealed on the 3rd floor directly across 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.
- Potential for harm · D2023-05-12 · 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 observation, interview and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced dignity and respect for 1 of 19 Residents (Resident #72) reviewed for resident rights in that: LVN A stood while feeding Resident #72 on 05/09/2023 during the noon meal. This failure could affect residents who required assistance with eating and could contribute to feelings of poor self-esteem and decreased self-worth. The findings included: Record review of Resident #72's face sheet, dated 05/09/2023, revealed he was admitted to the facility on [DATE] and again on 07/22/2022 with diagnoses which included autistic disorder (a developmental disability caused by differences in the brain), cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), and scoliosis (a sideways curvature of the spine). Record review of Resident #72's physician's orders, dated 07/22/2022, revealed an order for a diet: FMP,…
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 · D2023-05-12 · 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 6 residents (Residents #74) whose assessments were reviewed. Resident #74's Significant Change MDS dated [DATE], was coded to not be considered by the state level II PASRR while Resident #74 received PASRR services. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #74's face sheet, dated 05/10/2023, revealed the resident was admitted to the facility on [DATE] (original admission [DATE]) with diagnoses which included: attention deficit hyperactivity disorder, schizoaffective disorder, epilepsy, and unspecified mood affective disorder. Record review of Resident #74's PASRR Level 1 Screening, dated 09/01/2022, revealed there was evidence or an indicator Resident #74 was an individual that had an Intellectual Disability and there was evidence or indicators that Resident #74 was 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.
- Potential for harm · D2023-05-12 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 3 of 4 waste receptacles in that: There were two waste receptacles filled with waste that did not have tight fitting lids and one waste receptacle was overfilled and could not be closed outside the facility. These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings included: Observation on 05/10/2023 at 08:50 a.m. revealed there were four waste receptacles next to the dumpster outside the facility. One receptacle was closed with a lid; one receptacle could not be closed because the amount of waste in plastic bags inside the receptacle surpassed the top of the receptacle; one receptacle was overflowing with waste in plastic bags beyond the top and did not have a lid; and one receptacle was filled approximately 1/4th with loose waste and debris not sealed in a plastic bag. There were gnats too numerous to count flying around the dumpster and waste receptacles. Interview on 05/10/2023 at 9:12 a.m. with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-08-08 · tag F0576 — widespreadEnsure residents have reasonable access to and privacy in their use of communication methods.
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 residents had the right to send and receive mail, and to receive letters, package and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 5 of 5 residents (confidential residents) reviewed for resident rights. The facility failed to ensure staff distributed mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. These findings included: During a confidential resident council meeting, 5 of 5 residents present stated that they do not get mail on Saturdays, if mail comes on Saturday, it is not given out until Monday. During an interview via phone call on 8/7/2025 at 10:00 am Receptionist D-stated she worked weekends and the mail on the weekends usually comes in bulk and has a rubber band on it. She stated she does not go through the mail, and she puts it in the drawer for them to distribute on Monday.…
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
$24,285 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $14,063 — penalty dated 2024-06-27
- $10,222 — penalty dated 2024-05-17
- Medicare payment denial — starting 2024-07-31 for 72 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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 81% 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 $915K 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 455689. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-08, 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.