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Harmony Care At Stamford

1003 Columbia St, Stamford, TX 79553 · For profit - Corporation · 112 certified beds · (325) 773-3671 Medicare & Medicaid certified

Call the home — (325) 773-3671 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Nov 2023Behavioral-health or dementia-care citation — no harm found (F0758)$36,875 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $36,875 in federal fines (most recent 2025-04-30)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (66%) runs well above the national median (45%)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1303 Mabee Dr · (325) 773-3800 · Call to confirm hours
Pharmacy
2614 N Swenson St · (325) 773-2779 · Call to confirm hours
Grocery
382 E Main St · (325) 228-4268 · 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 4 of 5
Long-stay residentspeople who live here 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 whose need for help with daily activities increased34.5%15.8%15.4%worse
Long-stay residents who lose too much weight2.2%3.0%5.4%better
Long-stay residents with a catheter left in their bladder1.8%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 symptoms0.0%2.4%6.5%check this — see note marked star 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 whose ability to walk worsened19.4%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication19.4%18.0%18.9%typical
Long-stay residents given the seasonal flu vaccine97.1%98.0%95.3%typical
Long-stay residents with pressure ulcers0.0%3.8%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control11.4%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table11.1%9.6%17.1%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.

§ 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.

0.70U.S. median 0.31
Therapy hours / resident / day
0.50hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.70 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 0% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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

0.46
RN hours/ resident / day
1.01
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.69
Total nurse hours/ resident / day
0.31
RN hoursweekends
65.6%
Total nursing turnover
83.3%
RN turnover

How full it usually is: this home is certified for 112 beds and averages 31.8 residents a day — about 28% occupied, or roughly 80 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 3.69 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.60 hrs/resident/day on weekends vs 4.13 on weekdays — 37% thinner on weekends — a notable drop. RN hours go from 0.52 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 66% is well above the national median of 45%. 3 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

9
deficiencies at the latest standard inspection (2026-06-17)
6
at the previous standard inspection (2025-04-30)

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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · F2026-06-17 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review[KA73.1], the facility failed to maintain a quality assessment and assurance committee consisting at a minimum of the required committee members for 4 quarterly meetings reviewed for QAPI[KA74.1]. The facility did not ensure the Medical Director or a representative attended quarterly QAPI meetings. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings included: Record review of the Quality Assurance Performance Improvement Attendance Sign-In forms revealed:Sign in sheet for the 3rd Quarter 2025, undated, indicated the Medical Director was not present. Sign in sheet for the 4th Quarter 2025, undated, indicated the Medical Director was not present. Sign in sheet, dated January 2026, indicated the Medical Director was not present. Sign in sheet, dated 03/10/2026, indicated the Medical Director was not present. During an interview on 06/17/2026 at 12:10 PM, the ADMN stated no Medical Director was present for QAPI…

    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 plan of correction
  • Potential for harm · E2026-06-17 · 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, interview, and record review, the facility failed to ensure that the assessment accurately reflected the resident's status for 4 of 5 (Resident #1, Resident #2, Resident #18, and Resident #30) reviewed for accuracy of assessments. The facility failed to ensure Resident #1, Resident #2, Resident #18, and Resident #30 had tobacco use accurately coded on the admission/annual MDS assessment. This failure could place residents at risk for inadequate care and services to meet their needs.Findings included: During record review of Resident #1's electronic face sheet, dated 06/16/2026, revealed a [AGE] year-old male, admitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (a progressive, chronic lung disease that makes breathing difficult), dementia, major depressive disorder (a serious mental health condition characterized by persistent low mood and loss of interest in activities), anxiety, and high blood pressure. Record review of Resident #1's Annual MDS Assessment, dated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · E2026-06-17 · tag F0712 — pattern
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents were seen by a physician at least once every 60 days for 3 of 13 Residents (Resident #2, Resident #4, and Resident #16) whose records were reviewed for physician visits.The facility failed to ensure Resident #2's, Resident #4's, and Resident #16's primary care physician met with them as required.This failure could place residents at risk for medical needs not being addressed or met.Based on interview and record review, the facility failed to ensure the residents were seen by a physician at least once every 60 days for 3 of 13 Residents (Resident #2, Resident #4, and Resident #16) whose records were reviewed for physician visits.The facility failed to ensure Resident #2's, Resident #4's, and Resident #16's primary care physician met with them as required.This failure could place residents at risk for medical needs not being addressed or met.Findings included:Resident #2Review of Resident #2's electronic face sheet, dated 6/17/2026…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-06-17 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 1 of 13 residents (Resident #25) reviewed for informed decisions. The facility failed to ensure Resident #25 or their representative signed consent for psychotropic medication trazodone and sertraline prior to administering medication.This failure could place residents at risk of not being informed of their health status, which would allow them to make informed decisions regarding their care. Findings included: Record review of Resident #25's electronic face sheet, dated 06/17/2026 reflected an [AGE] year-old female, admitted [DATE], with the following diagnosis of depression, anxiety, 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.

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-06-17 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability or a related condition for level II resident review upon a significant change in status for 1 of 13 residents (Resident #28) reviewed for PASSR. The facility failed to follow up with the local authority for PASRR level II determination when Resident #28's PASRR level 1 dated 2.17.2024 screening reflected they were positive for Mental Illness. This failure could place residents at risk of not receiving specialized and/or habilitative services as needed to meet their needs. Findings included:Record review for Resident #28's electronic face sheet, dated 06.16.2026, revealed a [AGE] year-old female, admitted 03.01.2024, with diagnoses of bipolar disorder (a mental health condition that causes uncontrollable shifts in mood, energy and activity levels), Type II Diabetes Mellitus (metabolic disorder, high blood glucose levels),…

    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 plan of correction
  • Potential for harm · Dcited before2026-06-17 · 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 interviews and record reviews[KA41.1], the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care within 48 hours of a resident's admission for 1 (Resident #25) of 13 residents reviewed for care planning.The facility failed to develop a baseline care plan for Resident #25 within 48 hours of her admission.This failure could place residents at risk of not receiving effective, person-centered care.Record review of Resident #25's electronic face sheet dated 06/17/2026 reflected an [AGE] year-old female, admitted [DATE], with the following diagnoses of depression, anxiety, and dementia. Further review reflected resident was he own responsible party. Record review of Resident #25's admission MDS Assessment, dated 06/05/2026, reflected a BIMS score of 12, indicating cognitively intact.Record review of Resident #25's electronic medical…

    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 plan of correction
  • Potential for harm · Dcited before2026-06-17 · 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 that included measurable objectives and time frames to meet, attain, or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Residents #1 and Resident #30) reviewed for care plans. The facility failed to ensure Resident #1 had a care plan in place for smoking. The facility failed to ensure Resident #30 had a care plan in place for smoking. This failure could place residents at risk of not receiving individualized care and services to meet their needs.Findings included: Review of Resident #1's electronic face sheet dated 06/16/2026, revealed a [AGE] year-old male admitted on [DATE] with medical diagnoses of chronic obstructive pulmonary disease, dementia, major depressive disorder, anxiety, and high blood pressure. Review of Resident #1's Annual MDS Assessment, dated 02/16/2026, revealed in Section…

    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 plan of correction
  • Potential for harm · Dcited before2026-06-17 · 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 residents who on interview, and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 of 13 residents (Resident #4) reviewed for medical records. The facility failed to obtain physician orders with setting and parameters for use of CPAP for Resident #4.This failure could place residents at risk for respiratory illnesses and risk for respiratory failure. Findings included:Record review of Resident #4's electronic face sheet 06.15.2026, revealed a [AGE] year-old male, admitted 04.24.2025, with diagnosis Chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood stream), morbid obesity, Congestive Heart Failure (chronic condition of heart muscle is too weak), Presence of Cardiac Pacemaker(battery operated implanted device to regulate abnormal heart rhythm) Record review of Resident #4's Physician orders, dated 06.01.2026, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-06-17 · 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 interview, and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 2 of 13 residents (Resident #28 and Resident #30) reviewed for medical records. The facility failed to ensure Resident #28, and Resident #30 had safe smoking assessments completed. This failure could place residents at risk of health and safety due to no updated safe smoking assessments.Findings included:Record review of Resident #28's electronic face sheet, dated 06.16.2026, revealed [AGE] year-old female, admitted n 03.01.2024, diagnosis included of bipolar disorder (a mental health condition that causes uncontrollable shifts in mood, energy and activity levels), Type II Diabetes Mellitus (metabolic disorder, high blood glucose levels), Hypertension (high blood Pressure), Major Depressive Disorder. Record review of Resident #28's Annual MDS dated 03.10.2026 revealed Resident #28 Section A Level II PASRR (Preadmission Screening and Resident Review) Serious…

    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 plan of correction
  • Potential for harm · E2025-04-30 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every three months for 7 (Resident #3, Resident #4, Resident #5, Resident #7, Resident #8, Resident #10, Resident #16) of 12 residents reviewed for MDS assessments. The facility failed to complete Resident #3's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #4's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #5's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #7's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #8's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #10's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed 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
Show the remaining 13 citations
  • Potential for harm · Ecited before2025-04-30 · tag F0656 — failed to write and follow a full care plan — pattern
    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 interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #11, Resident #70) of 14 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes for hospice services for Resident #11. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes for Oxygen use for Resident #70. This failure could place the residents at risk for decreased quality of life and not having their needs met. Findings include: Record review of Resident #11's electronic face sheet 04/30/2025 revealed [AGE] year-old male admitted [DATE] and diagnosis included Chronic Obstructive Pulmonary…

    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 before2025-04-30 · 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 residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 (Resident #2 Resident #70) of 3 residents reviewed for respiratory care. 1. The facility failed to obtain a Physician's order for Resident #2's continuous supplemental oxygen. 2. The facility failed to obtain a Physician's order for Resident #70's continuous supplemental oxygen. 3. The facility failed to post oxygen in use sign for Resident #70. These failures could place residents at risk of not receiving the necessary respiratory care to meet their needs. Findings included: Record review of Resident #2's electronic face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: pneumonia, chronic pulmonary disease, emphysema. ( Lung disease) Record review of Resident #2's admission…

    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 · E2025-04-30 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days and to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 (Resident #10, Resident #127, and Resident #147) of 12 residents reviewed for unnecessary medications. The facility failed to ensure Resident #10's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. The facility failed to ensure Resident #127's PRN Alprazolam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. The facility failed to ensure Resident #147's PRN Lorazepam (medicine used to treat the symptoms of anxiety) and Haloperidol (medicine used to treat agitation) was discontinued after…

    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 · E2025-04-30 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure 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 each resident's drug regimen was free of significant medication errors for 2 (Resident #15 and Resident #174) of 12 residents reviewed for medications. The facility failed to hold Carvedilol (medication to lower blood pressure) per parameters stated in physicians' orders for a total of 15 doses in April 2025 for Resident #15. The facility failed to hold Lisinopril (medication to lower blood pressure) per parameters stated in physicians' orders for a total of 5 doses in April 2025 for Resident #15. The facility failed to hold Midodrine (medication to increase blood pressure) per parameters stated in physicians' orders for a total of 19 doses in April 2025 for Resident #15. The facility failed to administer Clonidine (medication to lower blood pressure) per parameters stated in physicians' orders for a total of 31episodes of high blood pressure in April 2025 for Resident #174. The deficient practice placed the residents at risk of harm or 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 before2025-04-30 · 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 interviews and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 1 (Resident #2) of 12 residents reviewed for baseline care plans. The facility failed to ensure that Resident #2 had baseline care plan developed within 48 hours after being admitted to the facility on [DATE]. These failures placed the residents at risk of not having continuity of care to safeguard against adverse events that are most likely to occur right after admission. Findings included: Review of Resident #2's electronic face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: pneumonia, chronic pulmonary disease, emphysema. Review of Resident #2's admission MDS assessment, dated 12/15/24, reflected a BIMS score of 15 which indicated no cognitive impairment. Review of Section O reflected Resident #1 was on continuous oxygen. Review of Resident #2's facility records reflected no evidence of a baseline care plan. During an interview on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-04-18 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    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 facility reviewed for environmental concerns. The facility failed to repair damaged walls in hot water closets located outside2, 3, 4, and 5 halls has damaged drywall with holes at the bottom and signs of rodent droppings. This deficient practice could place resident, staff, and the public at risk of an unsafe and unsanitary environment. The findings include: Observation on 04/17/2025 beginning at 2:15pm revealed the following: Hot water closets for halls 1, 2, 3, 4 and 5 had outside entry doors, all water heater closets had damaged drywalls at the bottom allowing access for rodents into inside walls of facility. Rodent droppings were observed in 5 of 6 closets around damaged drywall holes in water heater closet. Interview on 4/17/25 at 9:50am, the Administrator stated they were having issues with mice in facility, mice have been seen in halls and resident's rooms. The admin stated that their pest control vendor 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-04-18 · tag F0925 — failed to control pests — widespread
    Make 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

    Based on interviews and record reviews, the facility failed to provide a resident environment that was free of pests and rodents for 1 of 1 facility reviewed for effective pest control in that: The facility failed to maintain an affective pest control program. This deficient practice could place residents at risk of remaining in an environment that was not free of pests and rodents. The findings included: Record review of grievance log for January, February and March 2025 revealed 1 grievance about pest control. Record review of pest control log for the past 3 months revealed mice were targeted during visit by pest control vendor. Pest Control Vendor visits once per month. Interview on 4/17/25 at 9:50am, Administrator stated that they were having issues with mice in the facility. The Admin stated that their pest control vendor was working on problem. The admin stated that with the facility being located next to fields and an abandoned building next door is causing the mouse situation. Interview on 4/17/25 at 10:50am, Resident #1 stated she had rodent dropping in her room and had…

    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 · D2024-04-17 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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 housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior environment in 1 of 3 halls (Hall 1) observed for environmental conditions for Resident #1 and #2, in that: 1. The facility failed to prevent the temperature from being 86°F in Resident #1's room. 2. The facility failed to prevent the temperature from being 86°F in Resident #2's room The facility's failure placed the residents at risk for harm by a diminished quality of life and discomfort. The findings included: Resident #1 Record Review of the resident #1's Face Sheet dated 04/17/2024, revealed a [AGE] year-old male, admitted to the facility on [DATE], with a Diagnoses of Cerebral Infarction (stroke), diabetes, depression and hypertension (high blood pressure). Resident #1's MDS, dated [DATE], Section C revealed a BIMS score of 12 (moderately impaired). During an observation of temperature on 04/17/2024 at 2:56 PM 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-03-13 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 FY quarters reviewed (FY Quarter 1 2024 (October1-December 31) reviewed for administration. The facility failed to submit data to CMS for FY Quarter 1 2024 (October1-December 31). This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Record review of the facility's Civil Rights form (3761) dated 03/11/2024 provided by the Administrator indicated a total of 27 residents and 47 staff that included: 5-Registered Nurses 6-Licensed Vocational Nurses 12-Direct Care Staff 6-Dietary Staff 4-Housekeeping and Laundry 14-All others Record Review of the CMS PBJ report for CMS for FY Quarter…

    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 · Ecited before2024-03-13 · tag F0656 — failed to write and follow a full care plan — pattern
    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 and implement a person-centered, comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 5 (Resident #1, Resident #4, Resident #8, Resident #14, and Resident #24) of 5 residents reviewed for care plans. The facility failed to ensure care plans specified measurable objectives that could be evaluated or quantified for Resident #1, Resident #4, Resident #8, Resident #14, and Resident #24. This failure could place residents at risk for not receiving care and services individualized to meet their specific physical, mental, and/or emotional needs. Findings included: Review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of malnutrition (lack of proper nutrition), traumatic brain injury,…

    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 · E2024-03-13 · tag F0657 — failed to keep the care plan current — pattern
    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-centered comprehensive care plans within 7 days of a comprehensive assessment for 4 (Resident #1, Resident #4, Resident #8, and Resident #14) of 5 residents reviewed for care plans. The facility failed to review and revise Resident #1, Resident #4, Resident #8, and Resident #14's, Comprehensive Patient-Centered Care Plan within 7 days following the completion of a comprehensive assessment. The facility failed to review and revise Resident #8's Comprehensive Patient-Centered Care Plan to reflect a change in condition regarding the bed and chair alarms no longer necessary for the resident's safety. These failures could put residents at risk for not receiving the care and services needed to maintain or improve physical, mental, emotional, psychological well-being. Findings included: Review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-13 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 interview and record review, the facility failed to investigate an injury of unknown origin and report to HHSC for 1 out of 2 residents (Resident #1) reviewed for injury of unknown origin. The facility failed to report an injury of unknown origin, swelling and bruising around Resident #1's right eye, to HHSC. This failure could place residents at risk of abuse, fear, and a diminished quality of life. Findings include: Record review of Resident #1's electronic face sheet, dated 11/3/23 revealed she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include anxiety disorder, dementia, and scoliosis (a sideways curve of the spine). Review of Resident #1's progress notes dated 10/28/23, time entered 7:35 AM indicated During incontinence care (of Resident #1) CNA A noted swelling and a bruise to the right brow, the resident is unable to explain what happened, no other injuries were noted, no discomfort or distress is noted, will continue to monitor swelling and bruising.…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-13 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate an injury of unknown origin and report to HHSC for 1 out of 2 residents (Resident #1) reviewed for injury of unknown origin. The facility failed to complete an investigation of swelling and bruising around Resident #1's right eye first observed on 10/28/23. This failure could place residents at risk of abuse, fear, and a diminished quality of life. Findings include: Record review of Resident #1's electronic face sheet, dated 11/3/23 revealed she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include anxiety disorder, dementia, and scoliosis (a sideways curve of the spine). Review of Resident #1's progress notes dated 10/28/23, time entered 7:35 AM indicated During incontinence care (of Resident #1) CNA A noted swelling and a bruise to the right brow, the resident is unable to explain what happened, no other injuries were noted, no discomfort or distress is noted, will continue to monitor swelling 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.

    Freedom from Abuse, Neglect, and Exploitation 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

$36,875 in federal fines across 1 penalty.

  • $36,875 — penalty dated 2025-04-30

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.

Part of a chain

This home belongs to HARMONY CARE GROUP — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 51.6+0.4 vs chain
Health inspection 3 of 52.0+1.0 vs chain
Staffing 1 of 51.8-0.8 vs chain
Quality measures 4 of 53.4+0.6 vs chain
The other 5 homes this chain runs (chain average 1.6★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
FRIO HOSPITAL DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/15/2024
ELITE HC INVESTORS LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 12/15/2024
STAMFORD HOLDINGS BH, LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 12/15/2024
BODANSKY, HERSHELIndividual5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 12/15/2024
HELLER, YESHAYAIndividual5% OR GREATER MORTGAGE INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/15/2024
WEISS, CHAIMIndividual5% OR GREATER MORTGAGE INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/15/2024
RUFF, MICHAELIndividualCORPORATE OFFICERsince 12/15/2024
DH STAMFORD OPERATIONS, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/15/2024
STAMFORD ACAPELLA, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/15/2024
STAMFORD OPERATING LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/15/2024
CARPENTER, SCOTTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
EVANGELISTA, ANITAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/15/2024

CMS files one row per role, so the 22 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

$1.2M
Net patient revenuemost recent cost report
-23.7%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 69%Medicare 4%Other / private 27%

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

$255per resident / day
operating cost
$7,758per month
≈ monthly operating cost
$206per 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

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.

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 675769. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-17, 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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