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The Heights of Tyler

2650 Elkton Trail, Tyler, TX 75703 · For profit - Partnership · 120 certified beds · (903) 266-7200 Medicare & Medicaid certified

Call the home — (903) 266-7200 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Sep 20241 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$14,276 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2024
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,276 in federal fines (most recent 2023-09-01)
  • 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.

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

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2210 Three Lakes, Ste 100 · (903) 531-8890 · Call to confirm hours
Pharmacy
6991 Old Jacksonville Hwy · (903) 747-3508 · Call to confirm hours
Grocery
6991 Old Jacksonville Hwy · (903) 747-3503 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
6502 Old Jacksonville Hwy · (903) 534-1998

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 3 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 1 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.9%15.8%15.4%better
Long-stay residents who lose too much weight0.9%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.4%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.8%3.3%3.3%worse
Long-stay residents whose ability to walk worsened9.4%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.6%18.0%18.9%typical
Long-stay residents given the seasonal flu vaccine81.3%98.0%95.3%worse
Long-stay residents with pressure ulcers1.6%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control9.3%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table5.0%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine11.3%88.0%79.4%worse
Short-stay residents rehospitalized after admission23.6%25.7%22.6%typical
Short-stay residents with an outpatient ER visit15.5%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.412.171.67worse
Long-stay outpatient ER visits per 1,000 resident days1.822.061.80typical

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.

33.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

33.8%U.S. median 51.5%
Got home and stayed home
10.9%U.S. median 10.7%
Went back to hospital
48.0%U.S. median 56.6%
Met the expected recovery
0.35U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 48.0% 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 50 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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF33.8%CMS range 22.9–46.751.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 7.5–15.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge48.0%56.6%Oct 2024–Sep 2025CMS 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 discharge48.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge50.0%50.0%Oct 2024–Sep 2025CMS 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 identified97.1%98.7%Oct 2024–Sep 2025CMS 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 setting80.8%100.0%Oct 2024–Sep 2025CMS 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.6%CMS range 4.4–15.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.031.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.26
RN hours/ resident / day
0.80
LPN hours/ resident / day
2.06
Aide hours/ resident / day
3.13
Total nurse hours/ resident / day
0.27
RN hoursweekends
56.1%
Total nursing turnover
54.5%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 112.0 residents a day — about 93% occupied, or roughly 8 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 3.13 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 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 2.75 hrs/resident/day on weekends vs 3.28 on weekdays — 16% thinner on weekends. RN hours go from 0.26 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

6
deficiencies at the latest standard inspection (2026-02-25)
3
at the previous standard inspection (2024-10-30)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · K2023-09-01 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1of 6 residents (Resident #1) reviewed for significant medication errors. The facility did not provide Resident #1's physician ordered Potassium Chloride ER Tablet for four days. The noncompliance was identified as PNC. The IJ began on 8/12/2023 and ended on 8/17/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #1's face sheet, dated 8/25/23, indicated Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Stage 3 kidney disease (means your kidneys have moderate…

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

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Potential for harm · D2026-03-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet residents highest practicable physical, mental, and psychosocial needs for 1 of 4 residents reviewed for care plans, (Resident #1). Resident #1 was not care planned for making allegations of a consensual relationship with a staff member (CNA B), including that the staff member would no longer provide care for her. This failure could place residents at risk of not having their individualized needs met, and a decline in their quality of care and life. Findings included: Record review of the undated face sheet indicated Resident #1 was a [AGE] year-old female that admitted [DATE]. Record review of the physician's orders dated 3/24/26 indicated Resident #1 had diagnoses that included: Generalized Anxiety Disorder (persistent, excessive, and uncontrollable worry about every day, routine matters for at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-25 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure sanitation and housekeeping services were sufficient to maintain a clean and sanitary interior environment, including areas under resident's beds, for 4 of 11 resident rooms observed, (room [ROOM NUMBER] A & B, room [ROOM NUMBER] A & B, room [ROOM NUMBER] A & B, and room [ROOM NUMBER] A & B), observed for sanitary conditions. The facility failed to ensure and maintain a clean and sanitary interior environment, as evidenced by trash not empty, dust accumulation, debris, and lack of routine or incomplete daily housekeeping in resident's rooms and under-bed cleaning. These failures could result in inadequate sanitation, increased risk of respiratory irritation, infection, or pest attraction.Findings include: room [ROOM NUMBER]On 02/23/2026 at 9:30 AM, during an observation of room [ROOM NUMBER] A & B, revealed visible dust and lint accumulation, plastic spoons under the resident's bed, and scattered paper debris accumulated on the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews. the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 2 of 3 residents (Resident #18, Resident #63) reviewed for oxygen therapy. The facility failed to ensure Resident #18 received oxygen at the rate ordered by the physician. Resident #18's oxygen was set at 3.5 LPM on 2 consecutive days and at 4.0 LPM on the third day instead of 2 LPM as ordered by the physician.The facility failed to ensure Resident #63's nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) was stored in a bag when not in use. These failures could place residents who receive oxygen therapy at risk for respiratory distress and infection.The findings included: 1.Record review of a face sheet 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed food service safety , in that: *Steam tables were dirty with food spatter on glass on all 4 Satellite Kitchens *12 Dirty cookie sheets containing carbon build-up on rack *2 Dirty muffins pans containing carbon build up were stacked against each other *Dishwasher test log, had been filled in and completed for the entire day These failures could place residents who ate food from the kitchen at risk of foodborne illness Findings included: During observations and interviews on 02/23/2026, the following was noted in the kitchen and satellite kitchens: *At 8:45 AM there were carbon built up on 2 muffin pans stacked against each other, 12 large dirty cooking sheets with carbon build up on a rack in the main kitchen and the DM said that was a build up over years and would have to check on replacing them. *At 9:45 AM Hall 200 steam table glass had spatter on the glass and dirty bottom shelf. *At 11:06 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure MDS data accurately reflected the resident's status for 1 of 6 residents (Resident #76) reviewed for MDS accuracy. This facility failed to indicate Resident #76's current nutritional approach was by feeding tube in MDS dated [DATE]. This failure could put residents at risk for an inaccurate comprehensive assessment record. The findings included: Record review of Resident #76's undated face sheet indicated Resident #76 was an [AGE] year-old male admitted [DATE] with diagnoses including Dysphagia, Unspecified (difficulty swallowing), Gastrostomy Status (indicating a person has undergone a procedure resulting in a permanent opening in the stomach for nutritional support), and Gastro-Esophageal Reflux Disease without Esophagitis (a condition in which stomach acid frequently flows back into the esophagus). Record review of Resident #76's admission MDS dated [DATE] indicated Resident #76 had unclear speech, was rarely/never understood,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 meet professional standards of care for 1 of 6 residents (Resident #3) reviewed for professional standards when diagnosing a mental health disorder. The facility did not ensure Resident #3 had sufficient clinical documentation to support a new diagnosis of schizophrenia. This failure could place residents at an increased risk of inappropriate care planning, psychosocial stigma, and future treatment decisions based on incorrect clinical information. The findings included: Record review of Resident #3's undated face sheet indicated Resident #3 was an [AGE] year-old female originally admitted to the facility on [DATE] and most recently admitted on [DATE] and had the diagnoses of Alzheimer's Disease with Late Onset (a form of dementia that typically begins after the age of 65 characterized by memory and cognitive issues); Schizophrenia, Unspecified (a psychiatric diagnosis used when a person exhibits hallucinations, delusions, disorganized thinking, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-25 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, 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 for 1 of 4 residents (Resident #16) reviewed for pharmacy services. LVN C failed to flush Resident #16's enteral tube with water during medication administration as ordered by the physician. This failure could place residents who receive medications via a gastric tube (also called an enteral tube) at risk for tube occlusion (clogging), medication-nutrient interactions, reduced drug efficacy, and potential toxicity. Findings included: Record review of a face sheet dated 02/24/2026 indicated Resident #16 was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included spastic diplegic cerebral palsy (permanent, non-progressive neurological disorder appearing in infancy and caused by abnormal brain development),…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-30 · tag F0576 — isolated
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents had the right to have reasonable access to the use of a telephone and a place in the facility where calls could be made without being overheard for 3 of 7 residents (Residents #4, #27, #33, #36, #53, #58 and #85) reviewed for telephone use. The facility failed to provide a phone that could be used in an area, which would prevent resident conversations from being overhead. This failure could place residents at risk of having conversations being overheard and privacy rights not being respected. The findings included: During a group interview on 10/29/24 at 9:30 AM, Residents #4, #31 and #36 said the facility did not provide a phone for them to use, that would allow them to have a private conversation. They said the facility did not have a cordless phone for them to use and they had to use the phone at the nurse's station or the phone at the reception's desk. During an interview on 10/29/24 at 10:43 AM, LVN-A said the facility…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-30 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 for 1 of 4 residents (Residents #6) reviewed for pharmacy services. The facility failed to ensure a physician's order provided clearly written instructions for the dose of cholecalciferol (Vitamin D3) Resident #6 was to be given. This failure could place residents at risk for not receiving accurate doses of medications and the intended therapeutic response of prescribed medications. Findings included: A record review of Resident #6's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included Dementia (a group of thinking and social symptoms that may interfere with daily functioning) and Vitamin D (cholecalciferol) Deficiency. A record review of Resident #6's MDS 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-30 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #304) reviewed for infection control practices. 1.RN A failed to don appropriate PPE prior to providing wound care to Resident #304. 2.CNA B failed to don appropriate PPE prior to providing incontinent care to Resident #304. These failures could place the residents under their care at risk for exposure to possible transmission of communicable diseases and infections. Findings included: A record review of Resident #304's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #304 had diagnoses which included cerebral infarction (stroke), heart failure, chronic kidney disease, and indwelling urethral catheter (a thin tube that is inserted into…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · Ecited before2024-10-04 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were accurately documented for 2 of 3 residents (Resident #1 and Resident #2) reviewed for accurate medical records. MA C failed to correctly document in the EMR with regards to Resident #1's metoprolol Tartrate 50 mg, on 9/14/24. MA E failed to correctly document in the EMR with regards to Resident #2's entresto 24/46 mg adminstration on 9/29/24. These failures could place resident's at risk of unnecessary treatment, adverse drug reactions, or inadequate treatment. Findings included: Record review of Resident #1's face sheet dated 10/4/24 indicated she was [AGE] years old re-admitted to the facility on [DATE] with diagnoses including history of stroke, Type II diabetes, COPD ( chronic obstructive pulmonary disease-group of lung diseases that block airflow and make it difficult to breathe) A-Fib ( Atrial fibrillation is an abnormal heartbeat caused by…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-04 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for pharmacy services. MA B failed to hold Resident #1's metoprolol (a medication used to treat high blood pressure and elevated heart rate) when Resident #1's pulse was outside of the physician ordered parameters on 9/18/24 as well as 9/30/24. These failures could place residents at risk of receiving unnecessary medication and significant adverse effects from medication error. Findings included: Record review of Resident #1's face sheet dated 10/4/24 indicated she was [AGE] years old re-admitted to the facility on [DATE] with diagnoses including history of stroke, Type II diabetes, COPD ( chronic obstructive pulmonary disease-group of lung diseases that block airflow and make it difficult to breathe) A-Fib ( Atrial…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-18 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure resident who were transported by the facility were free from abuse for 1 of 1 resident (Resident #1 ) reviewed for abuse. The facility failed to ensure Resident # 1 was protected from abuse. The noncompliance was identified as PNC. The noncompliance began on 09/22/2023 and ended on 09/27/2023. The facility had corrected the noncompliance before the survey began. This failure had the potential to affect all residents who depend on the facility for transportation to medical appointments or other social outings. The findings included: Record review of Resident #1's face sheet, dated 09/18/24, indicated the resident #1 was re-admitted to the facility on [DATE], with diagnosis to include, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, unspecified severe protein-calorie malnutrition, other disorders of phosphorus metabolism (the body's phosphate levels are abnormal,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2024-08-28 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record 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 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for infection control practices. 1. The facility failed to ensure a wound vacuum cannister with red - brown liquid was not left in Resident #1's and Resident #2's room on 08/28/24. 2. The facility failed to ensure a brown substance was not present on the handrail in Resident #3's bathroom on 08/28/24. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1. Record review of Resident #1's face sheet, dated 08/28/24, indicated she was admitted to the facility on [DATE]. Her diagnoses included iron deficiency anemia secondary to blood loss (a deficiency 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-09-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen and 4 of 4 satellite kitchens reviewed for food service. Opened food packaging in the pantry and walk-in freezer were not closed after opening. Packages of food items were not labeled, dated, and re-sealed. A bulk container of popcorn had cups left inside the product. Food storage containers were not kept clean when stored. Satellite kitchens on the halls had soiled microwaves and dried coffee spills inside cabinet drawers. A carton of thickened liquid was not dated when opened. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations on 09/18/23, the following was noted in the kitchen: At 09:26 AM in the pantry a bulk plastic container of popcorn had a plastic cup and a Styrofoam cup stored inside the product. A plastic bag of raisin bran placed inside a zippered bag was not closed or dated and labeled. A 35 oz. bag of corn flakes was placed…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-20 · tag F0645 — isolated
    PASARR 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 the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident #102) reviewed for PASRR Level I screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #102. The PASRR 1 Level screening did not indicate a diagnosis of mental illness, although the diagnosis was present upon admission. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #102's face sheet, dated 09/20/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included post-traumatic stress disorder (a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). The onset date was 08/18/23.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #366) reviewed for respiratory care and services. The facility failed to obtain a physician's order for oxygen administration for Resident #366. The facility failed to follow their oxygen administration policy This failure could place residents at risk for developing respiratory complications. Findings included: Record review of Resident #366's face sheet, dated 09/19/23, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included encephalopathy (any disturbance of the brain's functioning that leads to problems like confusion and memory loss), cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area), and obstructive sleep…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-01 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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, medications were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 3 of 5 medication carts (100 Hall and 200 Hall Medication Carts) reviewed for pharmacy services. 1. RN G failed to ensure the Nurse Medication cart for 100 Hall was not left unlocked, unsecured, and unattended. 2. The facility failed to ensure the Nurse Medication Cart for 100 Hall and 200 Hall were not left unlocked, unsecured, and unattended near the nurse station. 3. The facility failed to ensure two medications (Fluticasone Propionate Nasal Spray 50 mcg and Ultra Lubricant Eye Drops) were left at Resident #2's bedside. 4. The facility failed to ensure CMA F did not leave a bottle of medication Phenytoin Extended Caps 100 mg (used to prevent and control seizures) on top of the 100 Hall medication cart unsecured, and unattended. These…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-01 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented, for 1 of 6 residents (Resident # 1) reviewed for resident records. The facility failed to accurately record Resident #1's Potassium Chloride ER on the MAR from 8/12/23 to 8/15/23. This failure could place residents at risk for incomplete and inaccurate clinical records which could lead to miscommunication, a delay in services or a potential decline in resident 's health. Findings include: Record review of Resident #1's face sheet, dated 8/25/23, indicated Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Stage 3 kidney disease (means your…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-09-20 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on an interview and record review, the facility failed to ensure that the facility's medical director or his/her designee attended the Quality Assessment and Assurance/Quality Assurance and Performance Improvement Committee meetings, for 1 of 1 facility, reviewed for QAA/QAPI. The facility failed to ensure the medical director attended their QAA and QAPI meetings for the months of January 2023, February 2023 and March 2023. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented. Findings included: Review of the facility's QAA/QAPI meeting signature logs for the months of January through March 2023, revealed, meetings were conducted each month during that period. Neither the Medical Director nor his/her designee signed the sign-in sheets, nor was it indicated on the sign-in sheet that the Medical Director or his designee attended the QAA/QAPI meetings from January 2023 to March 2023, via zoom or by phone. The signature sign-in log also indicated, the Medical Director only attended 5 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.

    Administration Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$14,276 in federal fines across 1 penalty.

  • $14,276 — penalty dated 2023-09-01

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 TOUCHSTONE COMMUNITIES — 25 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.9+0.1 vs chain
Health inspection 4 of 53.0+1.0 vs chain
Staffing 1 of 51.7-0.7 vs chain
Quality measures 3 of 54.0-1.0 vs chain
The other 24 homes this chain runs (chain average 2.9★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
LIBERTY COUNTY HOSPITAL DISTRICT NO 1Organization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/01/2017
CAPITAL FUNDING GROUP, INC.Organization5% OR GREATER MORTGAGE INTERESTsince 12/01/2014
STRATTON, CHARLESIndividualCORPORATE OFFICERsince 05/01/2005
TOUCHSTONE STRATEGIES-TYLER LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2017
BOENING, CHRISTOPHERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/13/2020
CAMPBELL, LESLIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2020
CASTILLO, LYNNEAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2017
MCGUIRE, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/08/2024
SEHLKE, BRYONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2017
SWEAT, STACYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/02/2025
ZUROVEC, DARRELLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2017
AEGIS THERAPIES, INC.OrganizationADP OF THE SNFsince 04/01/2017
CARVAJAL PHARMACY LTCOrganizationADP OF THE SNFsince 04/01/2017
NUTRITIOUS LIFESTYLES, INC.OrganizationADP OF THE SNFsince 04/01/2017
PLANTE & MORAN PLLCOrganizationADP OF THE SNFsince 04/01/2017
TOUCHSTONE COMMUNITIES INCOrganizationADP OF THE SNFsince 04/01/2017
TOUCHSTONE REALTY - SC LLCOrganizationADP OF THE SNFsince 04/01/2017
TRIDENT HEALTH SERVICES INCOrganizationADP OF THE SNFsince 04/01/2017
FELLBAUM, ERNESTIndividualADP OF THE SNFsince 04/01/2017
STUDER, STANLEYIndividualADP OF THE SNFsince 04/01/2017

CMS files one row per role, so the 28 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.

10 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.

$10.2M
Net patient revenuemost recent cost report
+6.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 57%Medicare 12%Other / private 32%

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

$249per resident / day
operating cost
$7,575per month
≈ monthly operating cost
$266per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676262. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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