Park Manor Of Tomball
250 School Street, Tomball, TX 77375 · For profit - Limited Liability company · 125 certified beds · (281) 516-7929 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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 (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $14,069 in federal fines (most recent 2025-06-09)
- 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)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 3 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.
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 | 6.4% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.8% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.6% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 2.4% | 6.5% | check this* — see note marked star 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 | 1.8% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.7% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.2% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.8% | 3.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 7.9% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.0% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.3% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 30.6% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.9% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.22 | 2.17 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.16 | 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.
42.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 81 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 67.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 46 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 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 41% 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 | 42.9%CMS range 36.0–54.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 7.0–15.6 | 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 | 67.4% | 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 | 80.4% | 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 | 52.2% | 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 | 87.0% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 95.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 | 6.2%CMS range 3.6–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.02 | 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 125 beds and averages 109.8 residents a day — about 88% occupied, or roughly 15 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 3.20 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.20 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.95 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 2.92 hrs/resident/day on weekends vs 3.31 on weekdays — 12% thinner on weekends. RN hours go from 0.21 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.
- Immediate jeopardy · J2025-06-09 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); for 1 of 4 residents (CR #1) when reviewed for quality of care. 1. The facility failed to notify CR#1's physician at 7 am when he had blurry vision, increased heart rate, shortness of breath, and his O2 levels dropped below baseline. 2. The first attempt at contact was made by text at 8:17 am but the NP did not respond until 9:30 am. CR#1 was transported to the hospital at 10am on 06/02/25, 3 hours after chief complaints of shortness of breath and unsuccessful interventions. An IJ was identified on 06/05/25. The IJ template was provided to the facility on [DATE] at 12:45pm. While the IJ was removed on 06/07/25, the facility remained out of compliance at a scope of isolated and severity…
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.
- Immediate jeopardy · Jcited before2025-06-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 based on the comprehensive assessment of a resident, that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 of 4 residents (CR #1, CR#2) reviewed for quality of care. 1. The facility failed to notify CR#1's physician at 7 am when he had blurry vision, increased heart rate, shortness of breath, and his O2 levels dropped below baseline. 2. The first attempt at contact was made by text at 8:17 am but the NP did not respond until 9:30 am. CR#1 was transported to the hospital at 10am on 06/02/25, 3 hours after chief complaints of shortness of breath and unsuccessful interventions. 3. The facility failed to notify the Doctor when CR#2 began to have open wounds to her lower legs, identified on 09/24/24. As wounds progressed, no treatments, new orders, or interventions were initiated. Resident was admitted to the hospital 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.
- Potential for harm · Ecited before2026-03-26 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 3 of 9 residents (Resident #1, # 86 and #95) reviewed for pharmaceutical services.The facility failed to ensure Resident # 95 received Levothyroxine daily as prescribed by the physician.The facility failed to administer the correct dose of Metoprolol (an antihypertensive medication) as physician ordered to Resident #1 on 03/25/26. The facility failed to administer Clonidine (an antihypertensive medication) as physician ordered when Resident #86's systolic blood pressures were greater than 150 on 03/01/26, 03/02/26, 03/03/26, 03/04/26, 03/07/26, 03/17/26, 03/16/26, 03/17/26 and 03/20/26.These failures could place residents receiving medications at risk of inadequate therapeutic outcomes, reduced quality of life and hospitalization.Findings included:Record 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.
- Potential for harm · Ecited before2026-03-26 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure all drugs and biologicals were stored securely for one of nine residents (Resident #86) and one of three medication carts (200 Hall nurse medication cart) reviewed for medication storage.The facility failed to keep resident medications stored securely. Two large white oblong tablets were found in Resident #86's possession with no nursing staff present.The facility failed to lock the 200 Hall nurse medication cart and secure an IV medication that was left on top of the cart prior to walking away. These failures could affect residents receiving medications placing them at risk of receiving the wrong medication, adverse side effects and drug diversion.Findings included:Record review of Resident #86's face sheet dated 03/25/26 revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. Resident #86's diagnoses included ESRD (end stage renal disease), dependence on renal dialysis, diabetes 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 · D2026-03-26 · tag F0552 — isolatedEnsure 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 observation, interview, and record review, the facility failed to ensure each resident was fully informed in a language that he or she could understand of his or her total health status, including but not limited to, his or her medical condition for 2 (Resident #86 and #75) of 8 residents reviewed for resident rights.The facility failed to communicate effectively with Resident #86 whose primary language was Spanish, and Resident #75 whose primary language was Vietnamese.This failure could place residents who communicate in a foreign language at risk of unmet needs.Findings included:1.Record review of Resident #86's care plan revealed it did not include any plan for addressing her ability to communicate. In an interview on 3/24/26 at 9:40 a.m. via translation line, Resident #86 stated that she had some complaints about care and medications but was unable to communicate those needs to staff due to being Spanish speaking. In an interview on 3/24/26 at 10:45 a.m. via translation line, Resident #86 stated…
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 before2026-03-26 · 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 for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 (Resident #9) residents reviewed for comprehensive assessments. The facility failed to ensure Resident #9's care plan addressed the resident's history of UTI (urinary tract infection) and interventions for UTI.These failures could place residents at risk of not having their individually assessed needs determined, monitored and met.Findings included:Record review of Resident #9's face sheet dated 03/25/26 revealed an [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. Resident #9's diagnoses included Dementia (a general term for a group of symptoms that cause a loss of cognitive functioning), Hemiplegia (one-sided…
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 · D2026-03-26 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #1) of 2 residents reviewed for enteral nutrition.LVN B failed to check for Gtube (gastrostomy tube) placement prior to administration of medications as per Physician orders and facility policy.This failure could place residents who receive medications or feedings via Gtube at risk of aspiration, pain and hospitalization.Findings included:Record review of Resident #1's face sheet dated 03/25/26 revealed a [AGE] year-old admitted to the facility 03/03/26. Resident #1's diagnoses included Hemiplegia (one sided paralysis or severe loss of strength on one side), Hemiparesis (weakness to one side of body), pneumonitis (swelling and irritation of lung tissue) due to inhalation of other solids and liquids, malnutrition, Dementia (a general term for a group of symptoms that cause a 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 · D2026-03-26 · 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 ensure bed rails were maintained and checked regularly to make sure they are installed correctly as rails may shift or loosen over time for 1 (Resident #14) of 10 residents reviewed for bed rails.The facility failed to ensure that Resident #14's bedrails were not loose.This failure could place residents at risk of injuries, entrapment or death. Findings included:Record review of Resident #14's face sheet dated 03/25/26 revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. Resident #14's diagnoses included fracture of the left femur, sepsis (blood infection), Dementia (a general term for a group of symptoms that cause a loss of cognitive functioning), muscle weakness and depression.Record review of Resident #14's quarterly MDS dated [DATE] revealed a BIMS score of 6 out of 15 indicating severe impaired cognition. Resident #14 used a manual wheelchair for mobility. Resident #14 required supervision…
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 before2026-03-26 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety reviewed for 1 of 5 (Dietary Manager) kitchen staff members. The facility failed to ensure food service staff wore appropriate hair nets while in the kitchen and food was being prepared.This failure had the potential to contaminate food and affect residents' health and safety.Findings included:During an observation and interview on 03/24/2026 at 8:11 am the Dietary Manager was cleaning the kitchen floors without wearing a hairnet. The Dietary Manager stated she had just returned from bringing the water hose inside to clean the floors. She stated she knew she should have word a hairnet due to the risk of hair contaminating food.During an interview with the Administrator on 03/25/2026 at 8:30am The Administrator stated that staff are expected to wear hairnets immediately upon entering the kitchen. The Administrator stated that failure to wear hairnets poses a risk for food contamination. Record review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-11-24 · tag F0609 — failed to report abuse allegations — patternTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were 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, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and 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 1 of 1 facility and 2 of 10 staff (MA A and LVN A ) reviewed for misappropriation. - The facility failed to report to the State Survey Agency allegations of drug theft and misappropriation of resident property by MA A. - The facility failed to report 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 · E2025-11-24 · tag F0610 — failed to investigate and act on abuse reports — patternRespond 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 ensure that all alleged violations involving abuse, neglect and injury of unknown origin, are thoroughly investigated and results reported of all investigations to the State Survey Agency, within 5 working days of the incident for 1 of 1 facility reviewed for misappropriation. - The facility Administrator failed to thoroughly investigate, put corrective actions in place and to report the results of the investigation to the state agency within 5 working days of the incident following allegations of drug theft and misappropriation of resident property by MA A - The facility Administrator failed to thoroughly investigate, put appropriate corrective actions in place and to report the results of the investigation to the state agency within 5 working days of the incident following drug theft of 80 controlled substance tablets that occurred on [DATE]. These failures could place residents at risk of drug diversion and misappropriation. Findings…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-24 · 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 acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and ensure it had a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that drug records were in order and an account of all controlled drugs was maintained and periodically reconciled for 1 of 10 staff (LVN A) for pharmacy services. - LVN A failed to maintain an accurate inventory of controlled substances when she failed to log into 80 controlled substances into the automated dispensing system on [DATE] which resulted in drug diversion. This failure could result in accurate controlled substance counts and drug diversion. Findings include: Record review of pharmacy delivery record dated [DATE] revealed, LVN A signed for a delivery of controlled substances that included: 1.…
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 16 citations
- Potential for harm · Dcited before2025-11-24 · 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, interview and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 10 staff (LVN A) reviewed for medication storage . - LVN A failed to ensure that controlled substances were stored behind a double lock when she left them unattended at the nursing station on [DATE] which resulted in 80 tabs of controlled medication stolen from the facility. This failure could place residents at risk of misappropriation of medications, adverse reactions to medications, overdose and hospitalization. Findings include: Record review of pharmacy delivery record dated [DATE] revealed, LVN A signed for a delivery of controlled substances that included: 1. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).2. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).3. 16 tablets 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 · Ecited before2025-06-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 40 of 106 residents reviewed for kitchen safety. 1. Dietary staff failed to ensure all perishable items were fresh before serving to residents. 2. During the lunch service on 06/09/25, Resident #1 took a sip of chocolate milk that had an expiration date of 05/19/25. This failure could place residents at risk of contracting a food borne illness. Findings include: Record review of Resident #1's face-sheet revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were type 2 diabetes, major depressive disorder, and morbid obesity. Record review of Resident #1's MDS (Minimum Data Set) assessment, Section C Cognitive Patterns dated 06/03/25 revealed a score of 11, signifying moderately impaired cognition. Record review of Resident #1's care plan revealed that she was dependent on staff for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-12 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 medication error rate was not five percent or greater. The facility had a medication error rate of 6.9 % based on 2 errors out of 29 opportunities, which involved 2 of 8 residents (Resident #15 and Resident #96) reviewed for medication errors in that:. - LVN L failed to administered medication as ordered to Resident #96 by administering Multivitamins w/ Minerals instead of plain Multivitamins as ordered. - LVN M failed to administer medications as ordered to Resident #15 by administering eye drops with Tetrahydrozoline Hydrochloride 0.05% instead of eye drops with Carboxymethylcellulose Sodium as ordered. These failures could place residents receiving medication at risk of inadequate therapeutic outcomes. Resident #96 Record review of Resident #96's Face Sheet dated 12/11/2024 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: end stage kidney disease (kidney reaches advanced state 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 · D2024-12-12 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all Pre admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Level II assessment for 1 of 2 residents reviewed for a mental illness, intellectual disability or developmental disability. (Resident #64) Resident #64 was admitted to the facility with a pre-admission screening reflecting no indicators of a mental illness when the resident had a diagnosis of Bipolar Disorder. This failure could place residents with mental illness, intellectual disability or developmental disability at risk for not receiving needed care and services to meet their needs or decreased quality of life. Findings included: Record review of Resident #64's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with disorder of the autonomic nervous system, history of transient ischemic attack, hemiplegia, and hemiparesis (partial paralysis of extremities), following…
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 · D2024-12-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 1 of 2 residents (Resident #96) reviewed for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, in that: Resident #96 was observed to not be repositioned off of sacral wound for a span of 4 hours. This failure could place residents at risk for skin breakdown or failure for ulcers to heal. Findings included: Record review of Resident #96's face sheet, dated 12/12/2024, reflected a [AGE] year-old male resident who was admitted to the facility on [DATE] with diagnoses including diagnosed with end stage renal disease and stage 4 pressure ulcer on the sacrum. Record review of Resident #96's MDS, dated [DATE], reflected the resident was at risk for pressure ulcers, he had a BIMS score of 10 indicating resident's cognition was moderately impaired and he needed substantial/maximal assistance for bed mobility. Record review of Resident #96's care plan, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-11-16 · tag F0727 — failed to provide required RN coverage — widespreadHave 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 observation, interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day 7 days a week from 10/2/2023 to 10/7/2023, 10/9/2023 to 10/13/2023, 10/15/2023 to 10/31/2023 and 11/1/2023 to 11/16/2023. The facility had no DON from 9/29/2023 to 10/10/2023. These failures placed the residents at risk for not having decisions made that would have required an RN to make in the management of the resident's healthcare needs and in managing and monitoring of the direct care staff. Findings: Record review of employee file revealed the previous DON termination date of 9/29/2023. Record review of employee file revealed current DON hire date of 10/10/2023. Record review of employee time stamps revealed no significant RN coverage for 10/2023 . Record review of employee files revealed no RN coverage from 11/1/2023 to 11/16/2023. In an interview on 11/15/2023 at 4:00pm with the DON, she said there were no health needs in the facility for RNs. She said they had no acuity for RNs. She said she had come into the facility on some…
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 · E2023-11-16 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to accurately assess each resident's status for 2 of 4 residents (Resident #52 and Resident #78) reviewed for assessment accuracy in that: - The facility failed to accurately assess and document Resident #78's use of hearing aids. - The facility failed to ensure Resident #52's MDS reflected the correct pain medication regimen. These failures could place residents at risk of not having accurate assessments, which could compromise their plan of care. Findings included: Resident #52 Review of Resident #52's Face Sheet dared 11/14/23 revealed, a [AGE] year-old female who was admitted to the facility on [DATE] with Diabetes type 2 as the primary diagnosis and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) as the secondary diagnosis. Review of Resident #52 physician's medication order dated 6/14/2023 revealed, Tramadol to be given every 6 hours for pain. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-16 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 8 residents (Resident #74) reviewed for quality of care. - The facility failed to properly assess Resident #74 when she returned to the facility with a dressing of approximately 5 X 5 inches located on her right chest under the collarbone from 11/07/23 to 11/14/23. This failure could place residents at risk of late identification of wounds and or worsening of current wounds as well as infection. Findings Included: Record review of Resident #74's Face Sheet dated 11/14/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: COPD, bipolar disorder, anxiety disorder, chronic pain syndrome, hypertension abd rheumatoid arthritis. Record review of Resident #74's Quarterly MDS dated [DATE] revealed, intact cognition…
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 before2023-11-16 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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, record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 8 residents (Resident#58) and 1 out of 4 Med Carts (400 Hall Nursing Cart) reviewed for pharmaceutical services. - The facility failed to ensure Resident #58's rapid-acting pre-prandial insulin (insulin that should be administered within 5-20 minutes before meals), NovoLog, was administered without regard to the facility scheduled or actual meal times. - The facility failed to ensure the 400 Hall nursing Cart did not contain expired liquid protein supplements. This failure could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and hospitalization. Findings Include: Resident #58 Record review of Resident #58's Face Sheet dated 11/16/23 revealed, a [AGE] year-old female who admitted to 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 · D2023-11-16 · 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, comfortable, and homelike environment for 1 of 8 Residents (Resident #78) reviewed for a safe, clean and homelike environment. - The facility failed to ensure Resident #38 had clean and unsoiled linens on his bed. This could place the residents at risk of decreased quality of like due to the lack of a well-kept environment. Findings included: Record review of Resident #38's Face Sheet dated 11/16/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: difficulty speaking, type 2 diabetes, high cholesterol, chronic kidney disease and high blood pressure. Record review of Resident #38's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 10, no behavioral symptoms, no rejection of car and setup or clean-up assistance with most ADLs. Record review of Resident #38's undated Care Plan revealed, no related focus…
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 · D2023-11-16 · 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 conduct a comprehensive assessment of a resident within 14 calendar days after admission for 1 of 21 residents (Resident #207) reviewed for comprehensive assessments, in that: - Resident #207 had no admission comprehensive assessment completed within 14 calendar days of admission. This failure may place residents at risk of not having all medical needs assessed and met. Findings included: Record review of Resident #207's face sheet , dated 11/16/2023, revealed a [AGE] year-old female was admitted into the facility on [DATE] and had diagnoses which included cerebral infarction, anoxic brain damage , acute respiratory failure, tracheostomy status and gastrostomy status. Record review of Resident #207's EHR revealed the resident had not yet had their MDS admission assessment completed, and the assessment reference date showed to be 2 days overdue. In an interview with MDS Nurse B on 11/16/2023 at 3:03 PM, she stated Resident #207's admission MDS 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 · Dcited before2023-11-16 · 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 observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet resident's medical, nursing and mental and psychosocial needs which were identified in the comprehensive assessment for 1 of 5 residents(Resident #78) reviewed for care plans. -The facility failed complete a comprehensive care plan that addressed Resident #78's use of hearing aids. This failure could place residents at risk of not having their needs met, decreased quality of life or injury. Findings included Record review of Resident #78's Face Sheet dated 11/16/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: epilepsy, hypotension (low blood pressure), anxiety, muscle wasting, and depression. Record review of Resident #78's admission Report dated 05/09/23 revealed, Resident #78 admitted with a left ear hearing aid.…
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 · D2023-11-16 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 irregularities noted by the pharmacist were acted upon for 1 (Resident #26) of 5 residents reviewed for pharmacy review. The facility failed to ensure: - The pharmacist's Director of Nursing Report dated October 13,2023 reflected order for Aspirin capsule 81mg daily be updated for Resident #26. - The pharmacist's Director of Nursing Report dated October 13, 2023, recommended changing Lipitor from morning to bedtime for Resident #26. These failures could place residents at risk for having a change in condition and not having the desired therapeutic effect. Findings included: Record Review of Resident #26's Face Sheet revealed an [AGE] year-old male who was admitted on [DATE] with a diagnoses of syncope and collapse (Fainting), chronic kidney disease (Damaged kidneys), hyperlipidemia (High Cholesterol (Fats), trans cerebral Ischemic attack (Brief blockage of blood supply to brain), atherosclerotic heart disease of native coronary artery without…
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 before2023-11-16 · 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
Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for 1 out of 4 medication carts ( 300 Hall Medication Aide Cart ) reviewed for medication storage. - The facility failed to ensure the 300 Hall Medication Aide Cart did not contain inappropriately labeled and in use protein supplements. These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings Included: In an observation and interview on 11/15/23 at 12:15 PM, inventory of the medication 300 Hall Medication Aide Cart with MA B revealed: - one open and in use bottle of Active Liquid Protein with no open date and manufacturers instructions to discard 3 months after opening. MA B said nursing staff are expected to check their carts daily as used for loose pills, inappropriately labeled and expired medications/supplements. He said multidose containers should be labeled with their open date in order 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.
- No harm found · C2025-11-24 · tag F0732 — widespreadPost nurse staffing information every day.
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 daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - The facility failed to update the facility nursing postings on 10/14/25 and 10/21/25. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include: Observations on Tuesday, 10/14/25, at 08:21 AM and 10:14 AM revealed, the facility Direct Care Report posting on the top of the nursing station facing the front door that read Monday [DATE]. The posting indicated that that the facility had a Day shift (6 AM and 6 PM) and Night Shift (6 PM- 6 AM) for LVNs, 3 Shifts ( 6AM- 2 PM, 2 PM - 10 PM, 10 PM- 6 AM) for CNAs, 2 shifts for CMAs (6 AM- 2 PM), 2 shifts for Restorative Aides (7:30 AM- 3:30 PM and 8 AM- 4 PM), 1 shift for RN Unit Mangers (8 AM - 4 PM) and 1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2023-11-16 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 2 of 8 residents (CR #1 and CR #2) whose records were reviewed for accuracy and completeness. - The facility failed to maintain complete and accessible records of medication administration times for CR #1 and CR #2. These failures could place residents at risk of having incomplete or inaccurate records. Findings included: CR #1 Record review of CR #1's Face Sheet dated 11/16/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: abscess of chest wall and hypertension. The resident discharged from the facility on 03/31/23. Record review of CR #1's MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, limited assistance with most ADLs, received PRN pain medication, received an anticoagulant, received an antibiotic,…
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
$14,069 in federal fines across 1 penalty.
- $14,069 — penalty dated 2025-06-09
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 HMG HEALTHCARE — 31 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 | 2 of 5 | 3.1 | -1.1 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 1 of 5 | 1.8 | -0.8 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 30 homes this chain runs (chain average 3.1★, 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 | Share | Since |
|---|---|---|---|---|
| CIBC BANK USA | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/01/2018 |
| FORVIS MAZARS LLP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/01/2018 |
| ZIONS BANCORPORATION | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/01/2018 |
| WINNIE-STOWELL HOSPITAL DISTRICT | Organization | DIRECT OWNERSHIP INTEREST | — | since 04/01/2018 |
| STRAMECKI, ANTHONY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2018 |
| MURRELL, EDWARD | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2018 |
| ROLLO, JEFFERY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2018 |
| BALSAMO, KRYSTAL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/29/2021 |
| BOAMAH, BERNADETTE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/20/2001 |
| CULP, ROLAND | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2012 |
| DASPIT, LAURENCE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2012 |
| DOHN, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/27/2019 |
| GUGGENHEIM, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/30/2022 |
| PICO, ANA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2012 |
| PRINCE, DEREK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2012 |
| QUINN, PETER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/19/2011 |
| REINARZ, CHRISTIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/13/2024 |
| VRATIS, KACEY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2018 |
| WAY, GEORGE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2018 |
| HEALTHMARK GROUP LTD | Organization | ADP OF THE SNF | — | since 09/11/2025 |
| HM GROUP LLC | Organization | ADP OF THE SNF | — | since 09/11/2025 |
| HMG HEALTHCARE LLC | Organization | ADP OF THE SNF | — | since 09/11/2025 |
| HMG PARK MANOR OF TOMBALL, L.L.C. | Organization | ADP OF THE SNF | — | since 09/11/2025 |
| STANBRIDGE, NORMA | Individual | ADP OF THE SNF | — | since 09/29/2014 |
CMS files one row per role, so the 37 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted.
8 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.
About 74% 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676165. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, 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.