The Villa At Texarkana
4920 Elizabeth St, Texarkana, TX 75503 · For profit - Limited Liability company · 106 certified beds · (903) 792-3812 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (59%) 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.0% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.9% | 3.0% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 7.2% | 2.4% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 3.3% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 11.9% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 28.1% | 18.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 4.2% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.6% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 37.1% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 27.7% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.46 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.10 | 2.06 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 22 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 34% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 24% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.1%CMS range 5.3–12.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 50.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 59.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 3.8–12.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.47 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 106 beds and averages 93.6 residents a day — about 88% occupied, or roughly 12 beds typically open. It runs fairly full. 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 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 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 2.97 hrs/resident/day on weekends vs 3.51 on weekdays — 15% thinner on weekends. RN hours go from 0.36 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 59% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2023-10-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 1 resident reviewed for accidents and supervision. (Resident #2) The facility failed to provide appropriate supervision for Resident #2 to prevent falls with and without injury. This failure places residents at risk for serious injury related to falls. Findings included: 1. Record review of an undated face sheet indicated Resident #2 was a [AGE] year-old male and admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) and repeated falls. Record review of the MDS dated [DATE] indicated Resident #2 was sometimes understood but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #1) reviewed for infection control practices. The facility failed to ensure CNA A performed hand hygiene and changed her gloves during Resident #1's incontinent care on 06/29/26. This failure could place residents and staff at risk for cross contamination and the spread of infection. The findings included: Record review of the face sheet, dated 06/22/26, reflected Resident #1 was an [AGE] year-old male who admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia (a decline in mental ability severe enough to interfere with daily life) without behaviors. Record review of the admission MDS assessment, dated 06/22/26, reflected Resident #1 had clear speech, was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-11 · tag F0679 — failed to provide activities — patternProvide 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 in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 1 memory care unit consisting of 14 residents reviewed for activities. The facility failed to provide meaningful activities for dementia residents on the memory care unit. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.Findings included: Record review of the March 2026 Group Activities Calendar posted in the memory care unit dining area revealed the following activities: 03/09/2026 03/10/2026 03/11/202610 a.m.-Exercise 10 a.m.-Dancing 10 a.m.-Sit to Fit1 p.m.- Bean Bag Toss 1 p.m.- Match Up 1 p.m.- Tic Tac Toe2 p.m.- Memory Lane 2 p.m.-Name that Tune 2 p.m.-Nail Care3 p.m.-[NAME] Toss 3 p.m.- Art Shop 3 p.m.-Match Up During an observation on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-11 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for kitchen sanitation. The facility did not ensure:1. The flour scoop was kept out of the storage container on 03/09/2026, 03/10/2026, and 03/11/2026.2. The deep fryer and stove were free of caked on grease. These failures could place residents at risk for cross contamination and food-borne illness.The findings included: During an initial tour observation in the kitchen on 03/09/2026 beginning at 9:00 a.m., it was revealed that the flour scoop was left inside the flour container. The deep fryer was located beside the stove with a small gap between them. There was solidified grease on the floor between the stove and the deep fryer, that was caked up around the legs of the deep fryer. The whole side of the stove had caked on yellowish-brown grease. The back of the deep fryer had thick layers of caked on grease that were yellowish-brown. The fryer baskets were hanging on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-11 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 1 of 22 residents (Resident #47) reviewed for comprehensive MDS assessment timing. The facility failed to complete Resident #47's annual comprehensive MDS assessment within 366 days of the previous comprehensive MDS assessment. This failure could place residents at risk of not having their needs met. The findings included: Record review the face sheet, dated 03/10/2026, revealed Resident #47 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of dementia (memory loss). Record review of Resident #47's annual MDS assessment reflected an ARD date of 01/28/2025. The next comprehensive MDS assessment should have been scheduled on or before 01/28/2026. Record review of Resident #47's annual MDS assessment reflected an ARD date of 02/27/2026, which indicated the comprehensive 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.
- Potential for harm · D2026-03-11 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete the quarterly MDS assessment not less frequently than every 3 months for 1 of 16 (Resident #62) residents reviewed for MDS completion. The facility failed to complete the quarterly MDS assessment for Resident #62, within 92 calendar days of the previous annual assessment dated [DATE]. These failures could place residents at risk of not receiving services to provide quality care.The findings included: 1. Record review of a face sheet dated 03/09/2026 indicated Resident #62 was a [AGE] year-old male that admitted on [DATE] with diagnoses of dementia (a progressive decline in mental ability-including memory, thinking, and behavior-that interferes with daily life and is not a normal part of aging), benign prostatic hypertrophy (a common, noncancerous condition in men over 50 where the prostate gland enlarges, pressing on the urethra and causing urinary issues like weak stream, frequency, and urgency), and hypertension (high blood pressure). Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-11 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure an accurate MDS assessment was completed for 1 of 16 residents reviewed for MDS accuracy. (Resident #8) The facility failed to accurately code Resident #8's psychotropic medication use. This failure could place residents at risk of receiving unneeded care and services.Findings included: Record review of an undated face sheet revealed Resident #8 was an [AGE] year-old female, admitted on [DATE] with the diagnoses of Alzheimer's disease (a progressive, incurable neurodegenerative disorder and the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive difficulties), and diabetes type II (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar). Record review of a quarterly MDS assessment dated [DATE] for Resident #8 revealed a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident environment remained free from accident hazards for 1 of 20 residents (Resident #84) reviewed for accident hazards.The facility failed to keep prohibited items, chemical insecticide (targeting roaches), out of Resident #84's room.This failure could place residents at risk for injury, harm, and impairment or death.Findings included: Record review of Resident #84's face sheet, dated 11/21/25, indicated he was a [AGE] year-old male, re-admitted to the facility on [DATE] and originally admitted on [DATE]. His diagnoses included Major Depressive Disorder (a common, serious mental health condition characterized by persistent sadness, loss of interest, and fatigue lasting at least two weeks, significantly impairing daily life), Cerebral Infarction (a type of ischemic stroke caused by a blockage in a blood vessel, leading to brain tissue death due to lack of oxygen and nutrient), and Pneumonia (an infection causing inflammation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-11 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to protect and promote the rights of the resident in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 18 residents (Resident #63, Resident #53) reviewed for resident rights. The facility failed to protect and value Resident # 63's rights when the facility failed to allow Resident #63 call the police to report a potential crime. The facility failed to protect and promote the rights of Resident #53 by not knocking on the door prior to entering the resident's room. This failure could place residents at risk for decreased quality of life, increased anxiety, decreased privacy, and increased stress. Findings included: Record review of Resident #63's face sheet dated 10/24/22 indicated he was [AGE] years old and admitted to the facility on [DATE] with diagnoses including Muscle Wasting and Atrophy (the loss of muscle mass and strength, often caused by disuse, injury, malnutrition, or neurological…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 23 residents reviewed for environment. (Resident #57 and Resident #72) 1. The facility failed to repair an electrical outlet in the room of Resident #57 a timely manner. 2. The facility failed to provide a functioning bed light pull string for Resident #72. These failures placed residents at risk of injury of, living in an uncomfortable environment and a decrease in quality of life and self-worth. Findings included: 1. Record review of the face sheet 12/10/24 indicated Resident #57 was [AGE] years old and was admitted on [DATE] with diagnoses including heart failure, dementia, and weakness. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #57 was sometimes understood and sometimes understood others. The MDS indicated a BIMS score of 07 indicating Resident #57 was severely cognitively impaired. The MDS indicated Resident #72 was dependent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-11 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that resident assessments accurately reflected the resident's status for 1 (Resident #20) of 12 residents reviewed for accuracy of resident assessments. The facility failed to ensure that Resident #20's MDS quarterly assessment accurately reflected the resident had 5 injections of insulin and had no UTI (urinary tract infection). This failure put residents at risk for not receiving care and services needed. Findings included: Record review of Resident #20's face sheet dated 12/09/2024 revealed she was a 77-years-old female, admitted to the facility on [DATE]. She had diagnoses of depression, obesity, glaucoma (a group of eye diseases that can lead to damage of the optic nerve) Record review of the quarterly MDS assessment dated [DATE] indicated Resident #20 had a BIMS of 15, which indicated no cognitive impairment. The MDS also revealed Resident #20 received injections of insulin for 5 days in the prior 7 days. The MDS was not coded for UTI.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · Dcited before2024-12-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 14 residents (Resident #66, Resident #72) reviewed for adequate supervision. The facility failed to ensure that Resident #66 and Resident #72 did not have cigarette lighters in their room and in their personal possession. This failure could place residents at risk for injury, harm, and impairment or death. Findings included: 1. Record review of the face sheet 06/26/24 indicated Resident #66 was [AGE] years old and was admitted on [DATE] with diagnoses including Addisonian Crisis (Adrenal crisis, is a life-threatening medical emergency that requires immediate treatment), Hypoglycemia (occurs when your blood sugar level drops too low), Type 2 Diabetes (a condition that occurs when the body doesn't use insulin properly, leading to high blood sugar levels). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #66 was understood 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.
- Potential for harm · D2024-12-11 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 attempt to use alternatives prior to installing a side or bed rail, obtain informed consent prior to installation, ensure correct installation, use and maintenance of bedrails for 1 of 23 residents (Resident #30) reviewed for bedrails . 1. The facility failed to ensure informed consent for the use of Resident #30's bed rails were obtained prior to installation. 2. The facility failed to obtain a bed rail assessment to assess the risk of entrapment for Resident #30's bed rails. These failures could place residents at risk of entrapment or injury. Findings included: Record review of Resident #30's face sheet, dated 12/11/24, indicated he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included anxiety disorder (mental health conditions that cause uncontrollable and excessive feelings of fear or anxiety that can interfere with daily life), and myopathy (disease that affects the muscles and causes them to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-11 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 2 of 5 residents (Resident #8 and Resident #18) reviewed for unnecessary medications. 1. The facility failed to ensure Resident #8 had an appropriate rationale for declining a GDR for her Zyprexa medication (an antipsychotic medication used to treat bipolar disorder). 2. The facility failed to ensure Resident #18 had an appropriate diagnosis for her prescribed Trileptal (it can treat epileptic seizures). This failure could put residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: 1. Record review of Resident #8's face sheet, dated [DATE], indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-11 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 12 resident personal refrigerators reviewed for food safety (Resident #75). The facility failed to ensure the refrigerator for Resident #75 did not contain expired bologna and milk. This failure could place resident at risk for food borne illnesses. Findings include: 1. Record review of Resident #75's face sheet dated 01/3/24 indicated Resident #75 was [AGE] years old male and was admitted on [DATE] with diagnoses including Edema (a condition where fluid builds up in the body's tissues, causing swelling), Muscle Weakness (occurs when your muscles are unable to contract properly, resulting in reduced strength), and Cerebral Infarction (a serious condition that occurs when blood flow to the brain is blocked, resulting in brain tissue death). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #75 was understood and understood others. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-11 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure the hand hygiene procedures were followed by staff involved in direct resident contact for 1 of 5 residents (Resident #59) reviewed for infection control. The facility failed to ensure Staffing Coordinator M performed appropriate hand washing after incontinent care was performed for Resident #59. This failure could result an increase the infections, cross contamination and decrease quality of life. Record review of face sheet date 12/10/2024 indicated Resident #59 was a [AGE] year old male initially admitted to the facility on [DATE] with a diagnoses which included unspecified dementia (a general term for dementia that doesn't have a specific diagnosis), anoxic brain damage (cerebral hypoxia occurs when the brain doesn't receive enough oxygen) and a personal history of urinary tract infections. Record review of a quarterly MDS dated [DATE] revealed Resident #59 had a BIMS score of 12 and the resident was usually understood 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.
- Potential for harm · Fcited before2023-11-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure all food items were labeled and dated. The facility failed to ensure a clean ice machine. These failures could place residents at risk of foodborne illness and food contamination. Findings include: During an observation on 11/13/23 at 8:53 a.m., there were 14 bags of a light brown triangle shaped food item in the pantry with no date or label. During an observation on 11/13/23 at 8:54 a.m., in the walk-in freezer there was 1 bag of round beige colored unknown food items on the floor with no label. There was 1 bag of square light brown unknown food items with no date or label. There were 2 bags round beige colored food item no date or label. There was 1 plastic bag of unknown frozen small round off white food items with no date or label. During an observation on 11/13/23 at 8:56 a.m., in the walk-in cooler there were 6 bags of a yellow liquid with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-15 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment 2 of 4 shower rooms reviewed for environment. (Shower # 1 and Shower # 4) The facility failed to clean and repair tiles in the facility shower room [ROOM NUMBER] and 4. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: During an interview on 11/14/23 at 3:30 p.m. with Resident # 82, she stated the showers in the shower rooms were bothering her. She said that there was mold growing on the tiles and the caulking was coming apart. She said that there were tiles that were broken and coming off the wall. She said the main reason why she was bothered by the showers was, there was mold or mildew on the tiles, in the broken tiles, and in the caulking on the floor and walls. She said that she wants the showers cleaned, the caulking restored, and the tiles replaced. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-15 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 21 residents (Residents #37, #78), reviewed for care plans. The facility failed to revise and update Resident #37's comprehensive care plan with new enteral feeding orders. The facility failed to revise and update Resident #78's comprehensive care plan for hospice services. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: 1. Record review of the undated face sheet indicated Resident #37 was a [AGE] year-old female that was admitted on [DATE]. Record review of the physician's orders dated 11/13/23 indicated Resident #37 had diagnoses that included: Major depression (persistently depressed mood or loss if…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 2 of 21 residents reviewed for ADLs. (Resident #3 and Resident #72) The facility failed to remove facial hair from female Resident #3. The facility failed to shave facial hair for male Resident #72. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: 1. Record review of Resident #3's admission Record dated 03/15/23 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Physical Debility (General debility is a state of general weakness or feebleness that may be a result or an outcome of one or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 2 residents (Resident #24 and #55) reviewed for respiratory care and services. The facility failed to ensure Resident #24's oxygen concentrator was set at 2 LPM, as ordered by the physician. The facility failed to change the filters on oxygen concentrator machines that were in use for Resident #55. This failure could place residents at risk for developing respiratory complications. Findings included: 1. Record review of Resident #24's face sheet, dated 11/14/23, indicated she was a [AGE] year-old female, admitted to the facility 09/13/23. Her diagnoses included polycythemia vera (a rare blood disorder in which there is an increase in all blood cells, particularly red blood cells), and asthma (a disease in which the airways clog…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-15 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 21 residents reviewed for pharmacy services. (Resident # 73) The facility failed to provide adequate supervision for Resident #73 during medication administration. This failure could place residents at risk for inaccurate drug administration. Findings included: Record review of the face sheet 11/14/23 indicated Resident #73 was [AGE] years old and was admitted on [DATE] with diagnoses including high blood pressure, chronic obstructive pulmonary disease (chronic lung disease), and low back pain. Record review of physician's orders dated 11/14/23 did not indicate Resident #73 could safely administer his own medications. Record review of the MDS dated [DATE] indicated Resident #73 was understood and understood others. The MDS indicated a BIMS score of 15 indicating Resident #73 was 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.
- Potential for harm · D2023-11-15 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 21 reviewed. (Resident #73) The facility failed to securely store over the counter medications for Resident #73. This failure could place residents at risk for adverse reactions. Findings included: Record review of the face sheet 11/14/23 indicated Resident #73 was [AGE] years old and was admitted on [DATE] with diagnoses including high blood pressure, chronic obstructive pulmonary disease (chronic lung disease), and low back pain. Record review of physician's orders dated 11/14/23 for Resident #73 did not indicate an order for Flonase Nasal Spray. There was an order dated 09/07/23 for Symbicort Inhalation Aerosol 160-4.5 micrograms/actuations 2 puffs inhale orally two times a day related to chronic obstructive pulmonary disease. Record review of the MDS dated [DATE] indicated Resident #73 was understood and understood others. The MDS indicated a BIMS score of 15 indicating…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-24 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1of 1 memory care unit reviewed for infection control and 6 of 24 residents observed during hydration pass. (Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11) The facility failed to ensure the ice scoop for the memory care unit was sanitarily stored while not in use. The facility failed to ensure CNA A did not use a contaminated ice scoop to fill the memory care unit residents' cups with ice. The facility failed to ensure HA C did not cross-contaminate each resident's cup while using an ice scoop to fill Resident #6, 7, 8, 9, 10, and 11's cups during hydration pass. The facility failed to ensure HA C stored the ice scoop sanitarily while not in use during hydration pass. These failures could…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-24 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to make prompt efforts to resolve grievances the resident may have for 1 of 28 residents (Resident #3) reviewed for grievances. The facility failed to make prompt efforts to resolve a Grievance/concern report when Resident #3's Representative #1 reported being concerned that another family member may be giving Resident #3 medication, because she noticed Resident #3's speech being different after the other family member visited. This deficient practice of not making prompt efforts to resolve grievances could place residents at risk for abuse, neglect, and not having their needs met. Findings included: Record review of Resident #3's face sheet dated 10/18/23 revealed Resident #3 was an [AGE] year-old male. Resident #3 was admitted to the facility initially on 3/20/23 and readmitted on [DATE] with diagnoses including Alzheimer's (progressive mental deterioration due to generalized degeneration of the brain), dementia (progressive or persistent loss of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-24 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 interviews and record reviews the facility failed to ensure each resident was free from abuse and neglect for 1 (Resident # 1) of 8 residents reviewed for abuse and neglect. The facility failed to ensure Resident #1, was free from verbal abuse when he was cursed at by CNA E during care. This failure could place residents at risk of serious harm from possible abuse and neglect. Findings included: Record review of the face sheet for Resident #1's dated 10/23/2023 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety (a feeling of fear, dread, and uneasiness). Record Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-24 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 interviews and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse to the state survey agency for 1 of 28 residents (Resident #3) reviewed for abuse, neglect, exploitation, and misappropriation of resident property. The facility failed to report an allegation of abuse within 2 hours after Resident #3's Representative #1 filed a Grievance/concern report on 8/01/23 about being concerned that another family member may have been giving Resident #3 medications because Resident #3's speech was slurred after the other family member visited. This deficient practice could place residents at risk for abuse, neglect, misappropriation of property, and not having their needs met. Findings included: Record review of Resident #3'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.
- Potential for harm · D2023-10-24 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 10 residents reviewed for care plans. (Resident #5, and Resident #4) 1.The facility failed to develop a comprehensive person-centered care plan including interventions for falls for Resident #5. 2.The facility failed to develop a comprehensive person-centered care plan including interventions for pain and opioid use for Resident #4 These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. Findings include: 1. Record review of a face sheet dated 10/23/2023 revealed Resident #5 was an 85- year-old male and was admitted on [DATE] with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm), hypertension (elevated blood pressure), and weakness Record review of the most recent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 2 of 12 residents reviewed for ADLs (Residents # 2 and Resident # 6) 1.The facility did not provide incontinent care for Resident #2 for 6-8 hours for 2 days 2. The facility did not provide scheduled showers for Resident #6. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings Include: 1.Record review of an undated face sheet indicated Resident #2 was a [AGE] year-old male and admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident's environment remained as free of accident hazards as possible for 1 of 11 residents reviewed for accidents hazards (Resident #1). 1.The facility failed to ensure the television cable cord was secured and not laying in Resident #1's floor of her room. This failure could place residents at an increased risk of injury. Findings included: 1.Record review of Resident #1's face sheet dated 8/1/22 indicated she was [AGE] years old and admitted to the facility on initially on 5/31/22 with diagnoses including Alzheimer's (progressive mental deterioration that can occur in middle or old age due to degeneration of the brain), dementia (progressive loss of intellectual functioning with impairment of memory, thinking, and behaviors), anxiety (feeling of worry, nervousness, unease), and depression (persistent sadness). Record review of Resident #1's quarterly MDS dated [DATE] indicated she was sometimes understood and sometimes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to CARING HEALTHCARE GROUP — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.0 | ≈ chain avg |
| Health inspection | 4 of 5 | 3.0 | +1.0 vs chain |
| Staffing | 1 of 5 | 1.9 | -0.9 vs chain |
| Quality measures | 4 of 5 | 3.8 | +0.2 vs chain |
The other 13 homes this chain runs (chain average 3.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MURRAY, LORRAINE | Individual | W-2 MANAGING EMPLOYEE | since 04/01/2022 |
| MURRELL, EDWARD | Individual | CORPORATE DIRECTOR | since 04/01/2022 |
| TXK MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2022 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner 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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675966. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-11, 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.