Advanced Rehabilitation And Healthcare Of Vernon
4401 College Dr, Vernon, TX 76384 · For profit - Corporation · 120 certified beds · (940) 552-9316 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 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 | 13.4% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.7% | 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 | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 8.5% | 2.4% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 6.0% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.4% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 38.5% | 18.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 85.6% | 98.0% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 1.8% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 11.7% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.3% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 85.4% | 88.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 16.7% | 25.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 17.2% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.88 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.59 | 2.06 | 1.80 | worse |
‡ 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.
52.4% 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 144 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.7% 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 62 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 0.29 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% 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 | 52.4%CMS range 44.2–59.5 | 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 | 9.2%CMS range 6.5–13.2 | 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 | 59.7% | 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 | 62.9% | 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 | 58.1% | 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 | 95.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 65.6% | 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 | 100.0% | 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 | 1.1% | 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 | 9.9%CMS range 6.1–16.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.36 | 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 120 beds and averages 100.8 residents a day — about 84% occupied, or roughly 19 beds typically open. It usually has some room. 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 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 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 3.29 on weekdays — 16% thinner on weekends. RN hours go from 0.73 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · E2025-08-08 · 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) to meet the needs for 1 of 6 residents (Resident #61) reviewed for pharmaceutical services. 1. LVN-B facility failed to administer medications to Resident #61 according to physician's orders.2. LVN-B left Resident #61's medication with her in a pill cup to take later. This failure could place residents who received medications at risk for not receiving the intended therapeutic benefit of the medications.The findings included: Record review of face sheet dated 08/06/2025 revealed a [AGE] year-old female admitted most recently on 05/26/2023 with diagnoses to include: right below knee amputation (leg surgically removed below the knee); muscle weakness (condition where muscles are not as strong as they should be); bipolar disorder (mental health condition characterized by extreme mood swings); acute…
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 · E2025-08-08 · 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 the facility's only kitchen residents as evidence by: The facility failed to ensure:A. The temperature of the walk-in freezer was below 0 degrees Fahrenheit; B. The [NAME] counter drawers and cabinets in the dining room were clean and not soiled;C. The refrigerator in the Activity Room was clean and not soiled, opened food items were placed in sealed containers and were labeled with a use by date. These failures could place residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated. The findings included: In an observation on 08/05/25 at 9:67 AM, during the initial tour of kitchen, the temperature of the walk-in freezer was 21 degrees Fahrenheit. Inside the freezer there was a tub of ice cream, soft to the touch and not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-08 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the transfer or discharge is documented in the resident's medical records and appropriate information is communicated to the receiving healthcare institution or provider for 1 of 2 (Resident #2) reviewed for discharges. 1. The facility failed to ensure the transfer or discharge was documented in the Resident #2's medical records.2. There was no documentation from the physician indicating that Resident #2 had specific needs that could not be met in the facility. These failures affected discharged residents and could place the residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal process.The findings included: Record review of the face sheet for Resident #2 dated 08/08/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included myocardial infarction (heart attack), acute kidney failure, thrombocytopenia (a medical condition characterized…
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 before2025-06-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1 on 06/11/2025. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 06/12/25, revealed a 78- year- old female admitted to the facility on [DATE] with diagnoses including age-related debility (physical and mental weakness), muscle weakness, muscle wasting and atrophy (partial or complete wasting away of the body). Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 required partial/moderate assistance with most activities of daily living…
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 · D2025-02-20 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident / and or their representative were invited to attend/participate attend and IDT in the care plan meeting including both the comprehensive and quarterly review assessments for with the participation of the resident for 1 of 6 residents (Resident's #1) reviewed for care plan timing and revision. The facility failed to ensure representatives/residents were invited to attend comprehensive care meetings for Resident #1. The facility failed to document the reason for the representative/resident non-participation in the care plan meeting. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. The findings included: In a record review of Resident #1's face sheet, dated 02/19/25, revealed the resident was a [AGE] year-old female, originally admitted to the facility on [DATE] and with the latest admission date of 09/19/24. 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 · E2024-06-06 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community, for 2 of 32 residents (Residents #19 and #105) reviewed for activity programming, as evidenced by: 1. Resident #19 did not have an in-room activity plan developed and implemented to meet her individual interests, abilities, and needs. 2. Resident #105 did not have an in-room activity plan developed and implemented to meet his individual interests, abilities, and needs. 3. There was not a system in place to identify the residents requiring one-to-one individual activity programming. This failure could place the residents at risk for isolation, decline in cognitive status, and decreased feelings 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 before2024-06-06 · 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 that were complete and accurately documented in accordance with accepted professional standards and practices for 8 of 32 residents (Residents #57, #8, #43, #68, #82, #100, #105, and #261) whose records were reviewed for accurate and complete documentation. 1. The facility failed to ensure physician orders were written for Resident #57 for dialysis. 2. The facility failed to ensure Resident #8's Out of Hospital - Do Not Resuscitate Order form included a date for the physician's signature and included the physician's license number. 3. The facility failed to ensure Resident #43's Out of Hospital - Do Not Resuscitate Order form included the physician's printed name. 4. The facility failed to ensure Resident #68's Out of Hospital - Do Not Resuscitate Order form included the physician's license number and was signed in the correct section for Physician Statement. 5. The facility failed to ensure Resident #82's Out of Hospital - Do…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-06 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 7 residents (Resident #90) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident# 90's MDS accurately reflected that he did not an enteral feeding tube. This failure could place residents at risk for not receiving care and services to meet their physical needs and promote feelings of well-being and quality of life. The findings included: Record review of Resident #90's admission profile, dated 6/6/24, reflected a [AGE] year-old male whose most recent admission date was 06/16/21. Resident #5 had diagnoses which included: cerebral infarct (a dead A condition caused by disrupted blood flow to the brain causing brain cells to die), hypertension (high bleed pressure) and atrial fibrillation ( an irregular heart rhythm causing inadequate blood flow to the body). Record review of Resident #90s admission MDS, dated [DATE], Section K0300 reflected Resident #90 did…
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 · D2024-06-06 · 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 the facility failed to ensure that drugs and biologicals were secured and stored in locked compartments, and permit only authorized personnel to have access to the keys for 1 of 3 medication carts (Hall 4 medication cart) observed for medication storage, in that:. The Hall 4 Medication cart was left unlocked. This failure placed the residents at risk for medications being misappropriated or for potential harm and adverse reactions from access to medications not prescribed for them. The findings included: In an observation and interview on 6/15/2024 that lasted from 09:03 AM to:9:25 AM the Hall 4 nurses' medication cart was left unlocked by RN F in the open hallway at 9:03 AM as she entered a resident's room to administer medications. There was no other nurse to attend the cart in the hallway of Hall 4. There was 1 housekeeping staff in the area of the cart. RN F returned to the cart and stated she should not have left theHall 4 medication cart unlocked and unattended in the hallway. She stated she left it unlocked because she was busy and nervous…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-06 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #71) when reviewed for infection control. 1.The facility failed to ensure CNA D washed or sanitized her hands between glove changes as appropriate while providing incontinence care for Resident # 71. This failure could place residents at risk for cross contamination and the spread of infection. The findings included: Record review of Resident #71's face sheet, dated 06/6/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #71 had diagnoses of: muscle weakness, and hemiplegia (paralysis of the right side of the body). and diabetes with hyperglycemia ( a condition that results from too much sugar in the blood which can result in the symptom 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.
Show the remaining 7 citations
- Potential for harm · Ecited before2023-11-19 · 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 that were complete, and accurate for 2 of 8 residents (Resident #1, Resident #2) reviewed for medical records. The facility failed to update the eMAR after medication administered for Resident #1 and Resident #2. This failure could place the residents at risk of medication errors which could result in incorrect treatment. Findings included: Record review of Resident #1's electronic health record revealed a [AGE] year-old female, admission date 1/28/2020, Diagnoses: chronic obstructive pulmonary disease (lung diseases that block airflow and make it difficult to breathe, severe protein-calorie malnutrition , repeated falls, other abnormalities of gait and mobility (change in walking pattern), muscle weakness (generalized), pain in right hip, muscle wasting and atrophy (wasting of muscle mass), major depressive disorder (persistent feelings of sadness and loss of interest), chronic pain syndrome (ongoing pain lasting longer than…
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 before2023-04-13 · 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 interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 4 of 4 Residents (Residents #54, #65, #75 and #85) reviewed for accuracy of assessment. 1. The facility failed to ensure Resident #54's MDS, dated [DATE], accurately reflected the residents use of antipsychotics. 2. The facility failed to ensure Resident #65's MDS, dated [DATE]accurately reflected the residents use of antipsychotics. 3. The facility failed to ensure Resident #75's MDS, dated [DATE], accurately reflected the resident had a diabetic ulcer. 4. The facility failed to ensure Resident #85's MDS, dated [DATE], Accurately reflected the residents use of antipsychotics. These failures could place residents at risk of not receiving the proper care and services due to inaccurate records. Finding include: 1. Record review of Resident #54's admission record revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included bipolar disorder (mental…
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 · D2023-04-13 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physicians' orders, the comprehensive person-centered care plan and the resident's goals and preferences for 1 of 3 residents (Resident #83) reviewed for receiving parenteral (administered through a vein) fluids. The facility failed to ensure Resident #83's midline intravenous catheter (an intravenous catheter that is suitable for long term infusion therapy) dressing to her right upper arm, was changed every Wednesday as ordered by her physician. This failure could place residents at risk of complications such as infection and/or sepsis and midline catheter displacement and/or infiltration. Findings include: Record review of Resident #83's face sheet, dated 04/10/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease (a circulatory condition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that 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 2 of 2 residents (Residents #22 and #43) reviewed for respiratory care. 1. The facility failed to ensure Resident #22's CPAP mask was kept in a bag while not in use. 2. The facility failed to ensure oxygen tubing for Residents #43 was changed weekly. These failures could place residents at risk for infections and transmission of communicable diseases. Findings include: 1. Record review of Resident #22's face sheet, dated 04/13/2023, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmission date of 03/02/2023. Resident #22 had diagnoses which included hypertension (high blood pressure), Obstructive sleep apnea (periods of not breathing while asleep) and a cognitive communicative deficit (not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-13 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 2 residents (Resident #102) reviewed for accuracy of medical records. The facility failed to ensure Resident #102 medical record was complete and included physician orders for continuous oxygen. This failure could place residents at risk of receiving inadequate care and services. Findings include: Record review of Resident #102's medical record revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the a diagnosis which included: Chronic Obstruction Pulmonary Disease with exacerbation (chronic lung disease characterized by air flow limitation). Record review of Resident #102's electronic medical records, dated on 04/10/2023 did not reflect an order for oxygen. During an interview with the ADON on 04/13/2023 at 2:00 p.m. revealed she was the one who was responsible 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 · Dcited before2023-04-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #31) residents reviewed for infection control. CNA C failed to thoroughly clean feces from the area between the buttocks and around the anus during incontinent care for Resident #31. This failure could place resident at risk of unnecessary infections. Findings include: Record review of Resident #31's Annual MDS, dated [DATE], revealed a [AGE] year-old female with an admission date of 04/02/18. Resident #31 had diagnoses which included, unspecified dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and hypertension (high…
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 · B2024-02-21 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
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 maintain all mechanical, electrical, and patient care Equipment in safe operating condition for 1 (Hot water heater) of 3 reviewed for essential equipment. The facility failed to repair or replace the hot water heater that supplied hot water for Halls 1, 2 and 3 for 7 days. This was determined to be past noncompliance because the facility took corrective actions prior to surveyor entry. This failure could place residents at risk for poor hygiene and health. Findings include: During an interview on 2/21/24 at 10:10am with the facility Administrator, Administrator stated on 1/31/24 the hot water heater which supplied hot water to Hall 1, 2 and 3 stopped working. The Administrator stated local plumbing was contacted. The blower motor on the water heater had failed and ordered a new blower. On 2/6/24 the blower motor was replaced by and hot water was restored to Halls 1, 2 and 3. The Administrator stated between 1/31/24 to 2/6/24 resident in Halls 1, 2, and 3 were able to take showers in rooms in Halls 4, 5 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ADVANCED HEALTHCARE SOLUTIONS — 28 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 | 4 of 5 | 2.9 | +1.1 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 3 of 5 | 2.0 | +1.0 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 27 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BAYLOR COUNTY HOSPITAL DISTRICT | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2014 |
| HARDIN, LESLIE | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | — | since 10/01/2014 |
| ADVANCED HCS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2021 |
| LICHTSCHEIN, TEDDY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2021 |
| MEISNER, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2021 |
| SCHEINER, ELIEZER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2021 |
CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 455931. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-08, 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.