No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Avir At Stephenville

1670 Lingleville Rd, Stephenville, TX 76401 · For profit - Corporation · 102 certified beds · (254) 968-2158 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jul 20242 immediate-jeopardy citations$204,614 in federal fines1 Medicare payment denial
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2024
  • 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
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $204,614 in federal fines (most recent 2024-06-14)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (82%) 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.

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

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
160 River North Blvd · (254) 918-2211 · Call to confirm hours
Pharmacy
150 River North Blvd · (254) 918-2201 · Call to confirm hours
Grocery
H-E-B1.2 mi
2150 W Washington St · (254) 965-7063 · Call to confirm hours
Park
1201 N Harbin Dr · Typically dawn to dusk
Place of worship
1302 N Harbin Dr · (254) 968-3770

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 fell from 2 to 1 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 rating1★
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 increased17.6%15.8%15.4%worse
Long-stay residents who lose too much weight1.5%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better 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 symptoms2.1%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.4%3.3%3.3%worse
Long-stay residents whose ability to walk worsened1.8%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication30.7%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers3.5%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control10.1%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.8%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication4.3%1.5%1.4%worse
Short-stay residents rehospitalized after admission24.4%25.7%22.6%typical
Short-stay residents with an outpatient ER visit18.3%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.282.171.67worse
Long-stay outpatient ER visits per 1,000 resident days2.772.061.80worse

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.

12.0%U.S. median 10.7%
Went back to hospital
0.31U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a 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 SNF12.0%CMS range 7.8–16.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at 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 hospitalization9.2%CMS range 5.2–15.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.581.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.28
RN hours/ resident / day
0.77
LPN hours/ resident / day
2.29
Aide hours/ resident / day
3.33
Total nurse hours/ resident / day
0.18
RN hoursweekends
82.3%
Total nursing turnover
90.9%
RN turnover

How full it usually is: this home is certified for 102 beds and averages 62.5 residents a day — about 61% occupied, or roughly 40 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 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.29 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 2.90 hrs/resident/day on weekends vs 3.51 on weekdays — 17% thinner on weekends. RN hours go from 0.32 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 82% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

2
deficiencies at the latest standard inspection (2025-07-24)
11
at the previous standard inspection (2024-06-14)

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.

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.

33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.

  • Immediate jeopardy · K2024-06-14 · tag F0694 — pattern
    Provide for the safe, appropriate administration of IV fluids 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 residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 resident (Resident #7) reviewed for peripheral intravenous care. 1. The facility failed to ensure LVN A administered Resident #7's IV (intravenous) antibiotics consistent with professional standards of practice and in accordance with physician orders. 2. The facility did not ensure Residents #7's central line dressings were changed per the physician's order. 3. The facility failed to draw labs weekly per physician orders while Resident #7 was on IV antibiotics. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:23 p.m. While the IJ was lowered on [DATE] at 11:22 p.m., the facility remained out of compliance at a severity level of no actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures placed…

    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
  • Immediate jeopardy · K2024-06-14 · 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 observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 2 residents (Resident #7 and #51) reviewed for medication errors. The facility failed to administer Resident #7's IV (intravenous) antibiotics as ordered by the physician on [DATE], [DATE] (two doses), [DATE], and [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:23 p.m. While the IJ was lowered on [DATE] at 11:22 p.m., the facility remained out of compliance at a severity level of no actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. The facility failed to ensure nursing staff administered Resident #51's Insulin Glargine as ordered by the physician. LVN N failed to administer Resident #51's Insulin Glargine 7 times during a 2-month review period, per physician order. RN F failed to administer Resident #51's Insulin Glargine 4 times during a 2-month review period, per physician order.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-05 · 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 interviews, and record review, the facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into a resident assessment, care planning, and transition of care for one (Resident # 9) of two residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting For resident #9. This failure could place residents who were PASRR positive at risk of not getting the PASRR services for a better quality of life and could lead to a decline in health. Findings included: Record review of Resident #9's face sheet dated 6/4/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: autistic disorder (a condition related to brain development that affects how people see others and socialize with them), unsteadiness on feet, bipolar disorder severe and depressed with psychotic symptoms ( a mental condition…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-05 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) to meet the needs for 1 of 5 residents (Resident #4) reviewed for pharmaceutical services, in that: The facility failed to reorder medication for Resident #4 before his supply was depleted. These failures could place residents who receive medications at risk for a decline in health and of not receiving the intended therapeutic benefit of the medications. The findings included: Record review of Resident #4's face sheet dated 6/5/26, revealed a [AGE] year-old male initially admitted on [DATE] with the following diagnoses: bladder disorder (a condition of the bladder that affects how the bladder stores or releases urine), UTI (an infection involving the bladder and kidneys) Record review of Resident #4's Quarterly MDS dated [DATE] revealed Section-C Cognitive Patterns Resident #4 had a BIMS score of 15, which…

    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 · D2026-03-27 · 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/ she preferred for 1 of 4 residents (Resident #406) reviewed for medication consents. The facility failed to ensure Resident #406 or their representative signed consent for hormone medication medroxyprogesterone acetate (Provera) (a female hormone prescribed to women to prevent pregnancy, hormone replacement therapy and management of abnormal uterine bleeding. When prescribed to men, the medication reduced testosterone levels, lowering sexual drive) prior to administering the medication. This failure could affect residents by placing them at risk of not being informed of their health status, which would allow them…

    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 · Ecited before2025-07-24 · 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 observation, interview and record review, 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, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #5, Resident #20 and Resident #53) reviewed for care plans in that: The facility failed to ensure Resident #5 had a care plan in place for use of a mechanical lift.The facility failed to ensure Resident #20 had a care plan in place for use of a mechanical lift.The facility failed to ensure Resident #53 had a care plan in place for hospice services. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs safely.The findings included the following:Resident #5Review of Resident #5's Resident Face Sheet dated 07/24/2025, revealed he was a [AGE] year-old male admitted to the facility on [DATE]…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-07-24 · tag F0849 — pattern
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 (Resident #53) of 4 residents reviewed for hospice services. The facility failed to maintain required hospice forms and documentation, that included:*the certificate of terminal illness and the hospice election form; *how the communication will be documented between the facility and the hospice provider; and *the physician certification and recertification of the terminal illness. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: Review of Resident…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to 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 3 of 4 (CNA-A, CNA-B, and CNA-C) staff observed during incontinent care. The facility failed to ensure that staff (CNA-A, CNA-B and CNA-C) performed proper peri-care (incontinent care) for Resident #1 and Resident #2. These failures placed residents of the facility at risk of infections from incontinent care. Findings included: Resident #1 Record Review of resident #1's Face Sheet dated 01/10/2025 revealed a [AGE] year-old male admitted on [DATE] and his latest admission on [DATE]. Review of Resident #28's diagnoses revealed: Hypertension (high blood pressure), and Lack of coordination. Record review of Resident # 1's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 06 (severe cognitively…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-23 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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, interviews, and record reviews the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment for 2 ( Resident #8 and Resident #10) of 6 residents reviewed for rights in that: 1. Resident #8's bathroom was observed to be unsafe and unsanitary. 2. Resident #8 and Resident #10 complained of roaches in their rooms and bathrooms. This deficient practice could place residents at risk of living in an unsanitary environment, and psychosocial harm due to diminished quality of life. Findings included: Record review of Resident #8's Face Sheet, dated [DATE], revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Acute (sudden) upper respiratory infection (a viral infection that affects the nose, sinuses, or throat), Complete lesion of L2 level of lumbar spinal cord (a spinal cord injury (SCI) that can cause permanent disability, significant morbidity, or even mortality), sequela (a condition which was 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure the resident environment remains free of accident hazards as possible 2 (Resident #7 and Resident #8) of 6 reviewed for accidents The DON brought a dog to work at the facility that bit Resident #7 on the ankle and was aggressive toward Resident #8. This was determined at no actual harm with the potential for more than minimal harm at past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation dated on 07/08/2024 when staff were in-serviced no dogs were allowed at the facility. This deficient practice could place residents at risk of an unsafe environment that could lead to a diminished quality of life. Findings included: Record review of Resident #7's Face Sheet, dated 07/23/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses of Major depressive disorder (a mental illness that can cause a persistent…

    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 · Past Non-Compliance
  • Potential for harm · D2024-07-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 reviews the facility failed to ensure resident had the right to be free from abuse for 2 (Resident #4 and Resident #5) of 7 residents reviewed for abuse and neglect. The facility failed to prevent CNA D from verbally abusing Resident #4 and Resident #5 on 07/04/2024 witnessed by RN C when she yelled, screamed, and slammed the door. These failures could place residents at risk of fear, emotional distress, and decreased quality of life, and further abuse. Findings included: Record review of Resident #4's Face Sheet, dated 07/23/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with of diagnoses of Ataxic (lack of voluntary muscle control) cerebral palsy (disorder that affects a person's ability to move, maintain balance, and posture) , Other speech and language deficits following nontraumatic subarachnoid hemorrhage (bleeding in the area between the brain and spinal cord) and cerebral infarction (condition that occurs when blood flow to the brain 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-23 · 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 observation, interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #4 and Resident #5) of 7 residents reviewed for abuse and neglect. The facility failed to report to the Health and Human Services Commission State Survey Agency and other officials when an alleged allegation of verbal abuse was reported by RN C when she witnessed CNA D verbally abuse Resident # on 07/04/2024. This deficient practice could place residents at risk of ongoing neglect. Findings included: Record review of Resident #4's Face Sheet, dated 07/23/2024, revealed a [AGE] year-old…

    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
Show the remaining 21 citations
  • Potential for harm · Dcited before2024-07-23 · 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 interviews and record reviews, the facility failed to have evidence that all violations in response to abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 2 (Resident #4 and Resident #5) of 7 residents reviewed for abuse and neglect. The facility failed to investigate the allegation of verbal abuse by CNA D on 07/04/2024 towards Resident #4 and Resident #5 witnessed by RN C. The failure could place residents at risk of allegation of abuse not being thoroughly investigated and at risk of ongoing abuse. Findings included: Record review of Resident #4's Face Sheet, dated 07/23/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with of diagnoses of Ataxic (lack of voluntary muscle control) cerebral palsy (disorder that affects a person's ability to move, maintain balance, and posture) , Other speech and language deficits following nontraumatic subarachnoid hemorrhage (bleeding in the area between the brain and spinal cord) and cerebral infarction…

    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 · Ecited before2024-06-14 · 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 record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 (Resident #2, Resident #7, Resident #28, Resident #51) of 18 residents reviewed for comprehensive care plans. The facility failed to develop a PASRR care plan Resident #2. The facility failed to develop care plan goals for Resident #28 related to his ADL Functions. The facility failed to ensure LVN N administered Resident #51's Insulin Glargine 7 times during a 2-month review period, per physician order. The facility failed to ensure RN F administered Resident #51's Insulin Glargine 4 times during a 2-month review period, per physician order. The facility failed to ensure LVN D administered Resident #51's Insulin Glargine 1 time during a 2-month review…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-14 · 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 observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' goals and preferences, for 1 of 18 residents (Residents #70) reviewed for respiratory care. The facility failed to ensure that Residents #70's oxygen tubing had been changed and dated once weekly. This failure placed residents that used oxygen/treatments at risk of respiratory complications and/or possible respiratory infections. Findings included: Review of Resident # 70's face sheet dated 06/14/2024 revealed an [AGE] year-old female admitted on [DATE]. Resident #70's diagnoses was, Chronic respiratory failure, heart disease, upper respiratory infection, cough, pain, anxiety, and shortness of breath. Review of Resident #70's Review of Resident #70's open ended (no end date) orders, dated 07/12/2023, revealed: Change nebulizer tubing every week…

    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 · E2024-06-14 · 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 interviews and record reviews the facility failed to ensure physician visits were conducted once every 30 days for 2 of 18 residents (Resident #2, Resident #73) and every 60 days for 4 of 18 residents (Resident #25, Resident #46, Resident #51, Resident #56) who were reviewed for physician visits. The facility failed to have Resident #2 seen by physician at least once every 30 days for the first 90 days after admission on [DATE]. The facility failed to provide documentation that Resident #2 was seen in April 2024. The facility failed to have Resident #73 seen by physician at least once every 30 days for the first 90 days after admission on [DATE]. The facility failed to provide documentation that Resident #73 was seen in March 2024, April 2024 and May 2024. The facility failed to have Resident #25 seen by physician at least every 60 days after the first 90 days for the past year from March 2023. The facility failed to provide documentation that Resident #25 was seen April 2023 and August 2023. 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-14 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, and record review the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance for 3 of 10 days reviewed for sufficient staffing. The facility failed to maintain nurse staffing at the level indicated by the PPD budget on 05/04/2024, 05/12/2024 and 06/01/2024. This failure could place the residents at risk of resident's needs, safety and psychosocial well-being not being met. Findings included: Record review of timesheets dated 05/04/2024 revealed 168.65 hours worked by direct care staff. Per facility PPD and census, 222.30 direct care staff hours were needed. Record review of timesheets dated 05/12/2024 revealed 199.39 hours worked by direct care staff. Per facility PPD and census, 228 direct care staff hours were needed. Record review of timesheets dated 06/01/2024 revealed 170.84…

    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 date of correction
  • Potential for harm · Ecited before2024-06-14 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to store medications in a locked compartment for 3 of 6 (Medication Cart 1, 2 and 3) reviewed for medication storage. The facility failed to keep each resident's medications in their original containers/packaging. This failure could result in drug diversion. Findings included: During an observation on 06/10/24 at 8:45 PM, RN K was passing medications on hall 3. She was observed with 7 unlabeled pill cups, on top of medication cart #1, that contained resident medications outside of their original blister pack container that included heart, pain, thyroid, and muscle relaxer, antibiotic, and prostrate medications. There were also 3 unlabeled pill cups inside the first unlocked drawer that included narcotics Oxycodone, Hydromorphone and Trazadone outside of their original blister pack container and not locked behind 2 locks. During an observation on 06/10/24 at 8:58 PM staff member RN J's medication cart #2 on Hall 4 had 2 unnamed pill cups with a Residents 10:00 PM crushed Hydrocodone (pain narcotic) in one 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-14 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 treat residents with respect, dignity, and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 18 residents (Resident #4) reviewed for resident rights. The facility failed to ensure staff treated Resident #4 with respect and dignity while performing wound care without the privacy curtain being pulled. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. Findings included: Resident #4 Review of Resident # 4's face sheet dated 06/14/2024 revealed an [AGE] year-old female admitted on [DATE] and her latest admission on [DATE]. Review of Resident #4's diagnosis revealed: Hypertension (high blood pressure), Pseudomonas (type of bacteria), Diarrhea, and Pruritis (itchy skin). Review of Resident # 4's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 12 (moderately…

    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 · D2024-06-14 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services related to protecting the resident's privacy for 1 (Resident #28) of 18 residents reviewed for resident rights. 1. The facility failed to ensure staff treated Resident #28 with respect and dignity while performing peri-care without the privacy curtain being pulled. 2. The facility failed to ensure staff treated Resident #28 with respect and dignity while performing transferring of Resident from bed to chair with a Hoyer Lift without the privacy curtain being pulled. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. Findings included: Resident #28 Review of Review of Resident # 28's face sheet dated 06/14/2024 revealed a [AGE] year-old male admitted on [DATE] and her latest admission on [DATE]. Review of Resident #28's diagnosis revealed: Hypertension (high blood pressure), Lack of coordination, and Diarrhea. Review of Resident # 28's MDS assessment…

    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 · Dcited before2024-06-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 and assistance devices to prevent accidents for 1 of 1 resident (Resident #28) reviewed for accidents and supervision. The facility failed to ensure CNA and NA locked (legs MUST BE in the maximum OPENED/LOCKED position) the Hoyer (mechanical) lift during the transfer of Resident #28. This failure could place residents at risk of injuries. Findings included: Review of Resident # 28's face sheet dated 06/14/2024 revealed a [AGE] year-old male admitted on [DATE] and his latest admission on [DATE]. Review of Resident #28's diagnosis revealed: Hypertension (high blood pressure), Lack of coordination, and Diarrhea. Review of Resident # 28's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 15 (cognitively intact). Section H-Bladder and Bowel, resident always incontinent. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to 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 of 4 (CNA L and NA) staff observed during incontinent care. The facility failed to ensure that staff (CNA L and NA) performed proper peri-care (incontinent care) or proper hand hygiene for Resident #28. These failures placed residents of the facility at risk of infections from incontinent care. Findings included: Record Review of resident #28's Face Sheet dated 06/14/2024 revealed a [AGE] year-old male admitted on [DATE] and his latest admission on [DATE]. Review of Resident #28's diagnoses revealed: Hypertension (high blood pressure), Lack of coordination, and Diarrhea. Record review of Resident # 28's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 15 (cognitively intact). 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-04 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to store medications in a locked compartment for 2 of 3 (Hall 3 Medication Cart and Hall 5 Medication Cart) medication carts reviewed for medication storage. The facility failed to keep each resident's drugs in their original containers/packaging. These failures could place all residents at risk of harm or decline in health due to lack of potency of supplies, medications/biologicals or misappropriation of medications, or drug diversions. Findings included: During an observation on 04/02/2024 at 11:15 AM, the hall 3 medication cart had seven loose pills in the second drawer of the medication cart. The pills were loose under the blister packages of resident medications. During an interview on 04/02/2024 at 11:20 AM, LVN B identified the loose pills as one Lisinopril, one Midodrine, one Furosemide, two Keppra pills, one Zoloft and one Buspirone. LVN B stated there should not have been pills loose in the medication cart. LVN B stated this was not normally her cart and she had not had a chance to look through 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 treat residents with respect, dignity, and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 1 residents (Resident #1) reviewed for dignity. The facility failed to ensure Resident #1 was allowed to smoke as according to his request and smoking assessment. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. Findings included: Record review of Resident #1's face sheet dated 04/04/2024 revealed resident was a [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Age-related cognitive decline, Nicotine dependence, Unsteadiness of feet, high blood pressure, Major Depressive disorder, and anxiety. Review of Resident #1's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns Resident #1 had a BIMS score of 5 (sever cognitive impairment). Record review of Resident #1's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs for 1 of 2 (Resident # 1) residents reviewed for care plan completion. The facility failed to ensure Resident #1 had a comprehensive care plan with measurable objective and person-centered interventions specific to smoking safety and elopement. This failure could place residents at risk for not receiving appropriate supervision. Findings included: Record review of Resident #1's face sheet dated 04/04/2024 revealed resident was a [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Age-related cognitive decline, Nicotine dependence, Unsteadiness of feet, high blood pressure, Major Depressive disorder, and anxiety. Review of Resident #1's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns Resident #1 had a BIMS score of 5 (sever…

    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 · E2023-12-15 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    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 an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being for 4 of 13 residents (#6, #7, #8, #9) on the Secure Unit reviewed for activities, in that 1. Resident #6, #7, #8, #9 did not have an ongoing activity program designed to meet her interests. This deficient practice placed residents on the Secure unit at risk for isolation, low self-esteem, and decline in mental status. Finding Include: 1. Review Resident #6 face sheet dated 12/15/23 revealed an [AGE] year-old female, admitted to facility on 1/7/21 with diagnoses that included Gastrointestinal hemorrhage (bleeding in the gastrointestinal tract), Alzheimer's disease (neurodegenerative disease). Review of Resident #6's MDS assessment dated [DATE], BIMS score 4 (severe cognitive impairment) revealed under preferences for activities was not coded. Review of Resident 6's Care Plan dated 10/14/23 for Psychosocial…

    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 · E2023-12-15 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 3 of 6 (room [ROOM NUMBER], #204 and #206) rooms in the secure unit observed for environment. The window blind blades (white 2-inch vinyl blades) were broken or missing in residents' rooms #202, #204 and #206. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment . Findings include: Observation on 12/12 23 at 3:40 pm, revealed that Resident #6's room [ROOM NUMBER], Resident #8 room [ROOM NUMBER], and Resident #9 room [ROOM NUMBER]'s windows blinds (white 2-inch vinyl blades) were broken or missing blades. Resident's #6, #8 and #9's cognition was severely impaired and were not interview able. Record review of the Maintenance repair log for October 2023 through December 13, 2023, revealed no repair request was found for the damaged blinds in rooms #202, #204 and #206.…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-15 · 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 observation, interview, and record review, the facility failed to ensure that the residents who need respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-center care plan, the residents' goals, and preferences for 2 of 4 residents (Resident #11, Resident #13) reviewed for quality of care. The facility failed to ensure Resident #11 and Resident #13's nebulizer cup and tubing was kept in bag while not in use. This failure could place residents at risk for respiratory infections. The findings include: 1. Record review of Resident #11's MDS, [AGE] year-old male, admission assessment, dated 10/5/23 revealed Resident #11 was admitted to the facility on [DATE]. Cognitive patterns revealed a BIMS score of 10 (moderate cognitive impairment). Medical diagnosis revealed Cerebral infarction (stroke). Record review of Resident #11's Care Plan dated 11/7/23 revealed it did not include the use of nebulizer. Record review of Resident #11's Order summary…

    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 · E2023-04-28 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week in that: The facility had no RN coverage on 03/20/2022, 06/18/2022, 06/19/2022, 08/21/2022, 01/01/2023, 01/29/2023, and 03/25/2023. The facility had less than 8 consecutive hours of RN coverage on 04/30/2022, 05/22/2022, 08/28/2022, 10/30/2022, 04/14/2023, and 04/22/2023. This failure could affect residents at the facility by placing them at risk for not having their nursing and medical needs met. Findings Included: Record review of nursing staff schedules, daily staffing sheets, and RN time records between 03/10/2022 and 04/28/2023 revealed that the facility did not provide 8 hours of RN coverage on 7 days (03/20/22, 06/18/22, 06/19/22, 08/26/22, 01/01/23, 01/29/23, and 03/25/23) of the 118 days reviewed and did not provide RN services for a full 8 hours on 6 (04/30/22, 05/22/22, 08/28/22, 10/30/22, 01/14/23, and 04/22/23) of the 118 days reviewed. There was no scheduled RN coverage on January 1, 2023, and January 29, 2023.…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-28 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 observation, interview and record review, the facility failed to ensure the menu was followed, for 3 (Resident # 11, Resident #14 and Resident #53) of 13 residents observed during lunch meal on 04/25/2023. The facility failed to ensure Resident # 11, Resident #14 and Resident #53 received a garlic bread stick or an approved alternative during the lunch meal. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss. The findings include: Review of Resident #11's Quarterly MDS assessment dated [DATE] revealed, Section A- Identification Section revealed a [AGE] year-old female. C- Cognitive Behavior revealed a BIMS score of 5 (severely impaired cognitive); Section I - Active Diagnoses revealed Anemia, Diabetes, Dementia, and Malnutrition. Review of Resident #14's Annual MDS assessment dated [DATE] revealed, Section A- Identification Section revealed a [AGE] year-old female. C- Cognitive Behavior revealed a BIMS score of 2 (severely…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-28 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerator. The facility failed to ensure foods were sealed and/or labeled properly in dry storage. The facility failed to ensure all food was not past expiration date. These failures could place residents that eat from the kitchen at risk for food borne illnesses. Findings included: Observation of the kitchen on 04/25/23 between 9:35AM and 10:00 AM revealed the following: Refrigerator 1. Container of Beef Soup with a use by date of 4/19. 2. One container of cottage cheese with a use by date of 4/15. 3. One bag of shredded lettuce frozen. 4. One plastic bag with a seal of grated cheese with no use by date. Dry Storage 1. One plastic bag with a seal of tortilla chips with no use by date or label of food item. 2. One plastic bag with a seal of potato chips with no use by date or label of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-28 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on 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 to help prevent the development and transmission of communicable diseases and infections for 8 staff reviewed for infection control procedures. Facility staff failed to wear facemasks that covered the nose and mouth at all times when in the presence of residents. These failures could place residents at risk for the transmission of communicable diseases. Findings included: During an observation and interview on 04/25/23 at 09:25 AM, there was a nurse sitting at a central nurses' station with her mask hanging off her ear. ADM came to greet surveyors, and said the transmission was medium and they preferred for staff to wear masks if doing direct patient care or within 6 ft of residents. During an observation on 04/25/23 at 09:56 AM, a housekeeping staff on hall 4 was wearing a mask that was not covering the nose. A shower aide was wearing a mask that did not cover her nose. Residents were…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-28 · 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 observation , interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 2 (Resident # 57 and Resident # 35) of 18 residents reviewed for abuse. The facility failed to complete a thorough investigation and maintain documentation that an allegation of abuse for Resident #57 and Resident #35 were thoroughly investigated. This failure could place residents who report allegations of abuse at risk of not being thoroughly investigated. Findings include: Review of Resident #35's face sheet dated 04/28/2023 revealed a [AGE] year-old female admitted on [DATE], with the following diagnosis Dementia, Alzheimer's disease, and need for assistance with personal care. Review of Resident # 35's Quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 0 (Severe cognitive impairment Review of Resident #35's progress notes, written by LVN B , written on 11/20/2022 at 12:18 AM revealed nurse was called to unit by CNA. CNA said 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.

    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

$204,614 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $204,614 — penalty dated 2024-06-14
  • Medicare payment denial — starting 2024-07-17 for 15 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.

Part of a chain

This home belongs to AVIR HEALTH GROUP — 116 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 1 of 52.3-1.3 vs chain
Health inspection 2 of 52.4-0.4 vs chain
Staffing 1 of 51.8-0.8 vs chain
Quality measures 4 of 53.6+0.4 vs chain
The other 115 homes this chain runs (chain average 2.3★, per CMS)
1 of 5Avir At BanderaBandera, TX 1 of 5Avir At Cowhorn CreekTexarkana, TX 1 of 5Avir At DallasDallas, TX 1 of 5Avir At LindaleLindale, TX 1 of 5Avir at AdamsTemple, TX 1 of 5Avir at Arbor TerraceSan Angelo, TX 1 of 5Avir at BeaumontBeaumont, TX 1 of 5Avir at BeltonBelton, TX 1 of 5Avir at BoerneBoerne, TX 1 of 5Avir at BradburnGrand Saline, TX 1 of 5Avir at CaldwellCaldwell, TX 1 of 5Avir at Camp WoodCamp Wood, TX 1 of 5Avir at Citizens TrailTexarkana, TX 1 of 5Avir at ConverseConverse, TX 1 of 5Avir at GainesvilleGainesville, TX 1 of 5Avir at GarlandGarland, TX 1 of 5Avir at GiddingsGiddings, TX 1 of 5Avir at Heritage OaksLubbock, TX 1 of 5Avir at HillsboroHillsboro, TX 1 of 5Avir at HoustonHouston, TX 1 of 5Avir at Johnson CityJohnson City, TX 1 of 5Avir at KennedaleKennedale, TX 1 of 5Avir at KerrvilleKerrville, TX 1 of 5Avir at LongviewLongview, TX 1 of 5Avir at LubbockLubbock, TX 1 of 5Avir at Meadow CreekSan Angelo, TX 1 of 5Avir at MineolaMineola, TX 1 of 5Avir at New BraunfelsNew Braunfels, TX 1 of 5Avir at PatriotEl Paso, TX 1 of 5Avir at PortlandPortland, TX 1 of 5Avir at Rose TrailTyler, TX 1 of 5Avir at San AngeloSan Angelo, TX 1 of 5Avir at SeguinSeguin, TX 1 of 5Avir at TexarkanaTexarkana, TX 1 of 5Avir at Tierra EsteEl Paso, TX 1 of 5Avir at Veterans MemorialHouston, TX 1 of 5Avir at WestonTemple, TX 1 of 5Avir at WinnsboroWinnsboro, TX 1 of 5Avir at WoodlandsEastland, TX 1 of 5Brightpointe at Lytle LakeAbilene, TX

Showing 40 of 115; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
STEPHENS MEMORIAL HOSPITAL DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/28/2015
1670 LINGLEVILLE ROAD PROPERTY OWNER, LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 03/01/2025
WELLTOWER INCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 03/01/2025
WELLTOWER NNN GROUP, LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 03/01/2025
WELLTOWER OP, LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 03/01/2025
EASLEY, JAMESIndividualCORPORATE OFFICERsince 03/01/2025
ROLAND, BRIANIndividualCORPORATE OFFICERsince 02/14/2021
1670 LINGLEVILLE ROAD OPCO, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
FREUND, NOCHUMIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2025
TRAVITSKY, AARONIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2025
DAGAN, AMITAIIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/22/2025
ZUBAL, GARRYIndividualADP OF THE SNFsince 03/01/2025

CMS files one row per role, so the 17 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.

$6.7M
Net patient revenuemost recent cost report
+23.6%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 76%Medicare 11%Other / private 13%

About 76% 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.

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

$187per resident / day
operating cost
$5,695per month
≈ monthly operating cost
$245per 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 455744. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-24, 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.

What to do next