Ridgecrest Retirement and Healthcare Community
1900 W State Hwy 6, Waco, TX 76712 · For profit - Limited Liability company · 90 certified beds · (254) 776-9681 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $14,267 in federal fines (most recent 2025-06-15)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (82%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.2% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.5% | 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 | 0.4% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 3.6% | 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 | 1.7% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 19.7% | 14.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 6.9% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.6% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 12.1% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.1% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 94.8% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 34.3% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.3% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.76 | 2.17 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.30 | 2.06 | 1.80 | better |
‡ 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.
55.3% 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 69 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 35.7% 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 28 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 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 55.3%CMS range 42.4–65.4 | 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 | 9.8%CMS range 6.9–13.5 | 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 | 35.7% | 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 | 57.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 35.7% | 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 | 88.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.3%CMS range 3.2–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.10 | 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 90 beds and averages 73.5 residents a day — about 82% occupied, or roughly 16 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.
Weekend coverage: total nurse staffing is 2.58 hrs/resident/day on weekends vs 3.12 on weekdays — 17% thinner on weekends. RN hours go from 0.22 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 82% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Immediate jeopardy · K2025-06-15 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 9 Residents (Resident #53) reviewed for quality of care. The facility failed to provide needed care or services by failing to communicate to staff Resident #53's need for supervision while taking medications as stated in his Psych NP note dated 04/22/25, remain in room and ask to open mouth to check to see he swallowed his medication. This resulted in Resident #53 being able to pocket 21 pills that he planned to use to commit suicide and caused him to be sent to a psychiatric hospital on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 06/12/25 at 07:09 PM and an IJ template was given. While the IJ was removed on 06/15/25 the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that…
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 · E2025-06-15 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission as required for 3 (Resident #19, Resident #63, and Resident #168) of 5 residents records reviewed for comprehensive assessment accuracy and timing. The facility failed on 6/11/2025 to complete Resident #19, Resident #63, and Resident #168's comprehensive MDS assessments within 14 days following their admissions to the facility. This deficient practice could result in newly admitted residents not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident #19's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included stroke (when blood supply to part of the brain is suddenly reduced, leading to brain cell death and/or permanent damage), high blood pressure, diabetes mellitus (chronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-06-15 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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, interviews and record review the facility failed to develop a comprehensive person-centered care plan furnishing services to attain, or maintain, the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #19, Resident #63, and Resident #119) of 6 residents reviewed for comprehensive care plans. The facility failed on 6/11/2025 to develop and implement a comprehensive care plan for Resident #19 and Resident #63. The facility failed to care plan Resident #119's wound on her right foot. These failures place residents at risk of not receiving appropriate care and treatment. Findings included: In an observation and interview on 06/10/25 at 3:02 PM with Resident #19 who was in her room revealed a communication board on her bedside table. When asked if the communication board helped the resident communicate her needs/wants with facility staff she said sometimes. It was observed that the resident had a difficult time getting the words out that she was trying…
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 · E2025-06-15 · 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 which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of resident for 2 of 3 residents (Resident #60 and Resident #168), and 1 of 2 medication rooms (Medication room [ROOM NUMBER]) reviewed for pharmacy services. 1. The MA failed to check Resident #168's blood pressure prior to the administration of his Metoprolol (a medication used to lower blood pressure) on 06/11/2025 at 9:45am during medication pass observation. 2. The facility failed to ensure Resident #60's physician's ordered medication Hydralazine was available for administration. 3. The facility failed to ensure 1 of 2 medication rooms observed (Medication room [ROOM NUMBER]) was free from expired drugs. This failure could place residents at risk of low blood pressure, dizziness, risk of falling and hospitalizations. Findings include: 1.) Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect are reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 1 of 9 residents (Resident #53) reviewed for abuse and neglect, in that: The facility did not report an incident concerning Resident #53 when on 06/09/25 Resident #53 told the SW he was planning to commit suicide and was found to have hoarded 21 pills of his medication administration to do so. This deficient practice could place residents at risk of not having incident and accidents reported or investigated. Findings included: Review of Resident #53's Face Sheet dated 06/12/25 reflected a [AGE] year old male admitted to the facility on [DATE] with diagnosis that included Schizophrenia (mental health condition that affects how people think, feel,…
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 before2025-06-15 · 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 interviews and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 2 (Resident #119, and Resident #168) of 12 residents reviewed for accuracy of assessments. The facility failed on 6/11/2025 to ensure Resident's #119 and #168's comprehensive MDS assessments accurately reflected their healthcare status and needs. This deficient practice could have placed the resident at risk for inadequate care due to incomplete assessments. Findings included: Record review of Resident #119's face sheet dated 06/12/25 reflected Resident #119 was an [AGE] year-old female with an admission date of 05/20/25. Resident #119's diagnoses encephalopathy (a group of conditions that cause brain dysfunction. Brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe form), congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), hypothyroidism (a disorder…
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 · D2025-06-15 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to develop and implement a baseline care plan within 48 hours from admission for 1 of 5 resident (Resident #120) reviewed for care plans. The facility failed to ensure Resident #120 had a Baseline Care Plan that was due within 48 hours of admission to reflect the person-centered needs of Resident #120. This failure could place residents at risk of getting insufficient care and having personal needs not met and could result in diminished physical and psychosocial well-being. Findings include: Review of Resident #120's face sheet dated 06/12/25 reflected that he was a [AGE] year-old male admitted [DATE] with diagnoses of displaced fracture of anterior wall of right acetabulum(medial boundary of hip socket) (a serious injury often requiring surgery), muscle weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy), cognitive communication deficit (a communication problem caused by underlying cognitive impairments rather than a primary…
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 · D2025-06-15 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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 was given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living for 1 of 6 residents (Resident #19) reviewed for ADL activities. The facility failed on 6/11/2025 to provide therapy services to maintain or improve Resident #19's communication ability by not evaluating her communication deficit for intervention or improvements. This failure could place residents at risk of ADL decline, frustration, and decreased socialization. Findings included: Review of Resident #19's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included stroke (when blood supply to part of the brain is suddenly reduced, leading to brain cell death and/or permanent damage), high blood pressure, diabetes mellitus (chronic disease where the body does not produce enough insulin), non-Alzheimer's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-15 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 6.45%, based on 2 errors out of 31 opportunities, which involved 2 of 2 residents (Residents #60 and Resident #168) observed during medication administration for medication errors. The facility failed to ensure Resident #60's physician's ordered medication Hydralazine was available for administration on 06/11/2025 at 10:00 am during medication pass. The MA failed to check Resident #168's blood pressure prior to the administration of his Metoprolol (a medication used to lower blood pressure) on 06/11/2025 at 9:45am during medication pass observation. This failure could place residents at risk of low blood pressure, dizziness, risk of falling and hospitalizations. The findings included: 1.) Review of Resident #60's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with 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 · D2025-06-15 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability of services of a lesser intensity, for one of six residents (Resident #19) reviewed for specialized rehabilitative services, in that: The facility failed on 6/11/2025 to ensure Resident #19 received a PT/OT/ST evaluation and treat as indicated upon admission as ordered in her admission clinical records dated 4/30/2025. This failure could place residents at risk of decline or decrease in their physical capabilities and emotional distress. Findings included: Review of Resident #19's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included stroke (when blood supply to part of the brain is suddenly reduced, leading to brain cell…
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 before2025-06-15 · 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 and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 5 residents reviewed for wound care (Resident #119). LVN B failed to wash or sanitize her hands while going from a dirty to clean surface while performing wound care on 06/11/25 at 9:46 AM for Resident #119. This deficient practice placed residents at risk for cross contamination and the spread of infection. Findings included: Record review of Resident #119's face sheet dated 06/12/25 reflected Resident #119 was an [AGE] year-old female with an admission date of 05/20/25. Resident #119's diagnoses included encephalopathy (a group of conditions that cause brain dysfunction. Brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe form), congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · D2025-06-15 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolatedHave policies on smoking.
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 follow their own established smoking policy for 1 (Residents #63) of 2 residents reviewed for smoking. The facility failed on 6/11/2025 to ensure that Residents #63 did not keep their personal cigarette lighters in their room per facility policy. This failure could place residents at risk of an unsafe smoking environment and injury. Findings included: Review of the facility's undated Smoking Residents list provided by the facility, identified Resident #63 as a smoker. Review of Resident #63's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included cancer, high blood pressure, kidney failure, malnutrition, depression (sadness), white matter disease (damage to the white matter of the brain), and vitamin D deficiency. Resident #63's BIMS score was a 15, indicating she was cognitively intact. Review of Resident #63's care plan was attempted on 06/10/25…
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 · E2025-04-30 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to review and revise the person-centered, comprehensive care plan for 3 of 12 residents (Residents #10, #11 and #12) reviewed for comprehensive care plans. 1. The facility failed to ensure a care plan was developed to address Resident #10's falls on 4/19/2025 and 4/25/2025. 2. The facility failed to ensure a care plan was developed to address fall interventions for Resident #11 after falls on 3/18/2025, 3/24/2025, and 3/28/2025. 3. The facility failed to ensure a care plan was developed to address fall interventions for Resident #12 after falls on 3/13/2025 and two falls on 3/30/2025 . This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings included: 1. Record review of Resident #10's face sheet, dated 4/30/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included: Pneumonia (infection of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-17 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 5 residents (Residents #1) reviewed for resident rights in that: The facility failed to ensure Residents #1's call light was within reach on 12/13/24. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #1's admission record dated 12/17/24 documented a [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses which included: quadriplegia (serve medical condition characterized by the partial or total loss of function in all four limbs and the torso), lack of coordination (not being able to move your body smoothly and precisely, often resulting in clumsiness, stumbling, or jerky movement), essential primary hypertension (occurs when you have abnormally high blood pressure that's not the result…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-17 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 3 residents (Resident #3) reviewed for privacy in that: The facility failed to ensure CNA C provided respect and dignity by drawing the privacy curtain during peri care for Resident #3. The findings include: Record review of Resident #3's face sheet dated 12/13/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were, Pulmonary disease (Lung disease), Major depressive disorder, Shortness of breath, Muscle wasting and atrophy, Need for assistance with personal care, Cognitive communication deficit, Limitation of activities due to disability and Abnormalities of gait and mobility. Record review on 12/13/24 of Resident #3's quarterly MDS assessment, dated 09/20/24 revealed a BIMS of 03 indicating severe cognitive impairment. Record review on 12/13/24 of Resident #3's care plan dated 01/14/24 reflected resident had ADL self-care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-17 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 5 residents (Residents #1) reviewed for resident rights in that: The facility failed to ensure Residents #1's care plan reflected his current food diet. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #1 's admission record dated 12/17/24 documented a [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses which included: quadriplegia (serve medical condition characterized by the partial or total loss of function in all four limbs and the torso), lack of coordination (not being able to move your body smoothly and precisely, often resulting in clumsiness, stumbling, or jerky movement), essential primary hypertension (occurs when you have abnormally high blood pressure that's not 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 · D2024-12-17 · 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 residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 4 residents (Residents #2) reviewed for quality of care in that: The facility failed to ensure Resident #2's oxygen mask and tubing, that were observed on 12/13/24 at 3:30pm, were not bagged for sanitation when not in use. This failure could affect residents who received oxygen therapy, by place them at risk for respiratory infections. The findings included: Record review of Resident #2's face sheet on 12/13/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were Hypertension, Type 2 diabetes, , Seasonal Allergy , Atrial fibrillation (irregular and rapid heartbeat) , Major depressive disorder and COPD. Record review on 12/13/24 of Resident #2's quarterly MDS assessment, dated 10/83/24 revealed a BIMS of 11 indicating her cognition was moderately impaired. Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new pressure ulcers from developing for one (Resident #1) of four residents reviewed for pressure injuries. The facility failed to ensure all wound care treatments were completed and documented during the month of August 2024 for Resident #1. This deficient practice could place residents at risk of improper wound management and deterioration in existing pressure injuries. Findings included: Review of Resident #1's face sheet revealed a male who was admitted on [DATE], discharged on 09/09/24, and his own RP. Review of Resident #1's medical diagnoses revealed he had diagnoses including cognitive communication deficit, type 2 diabetes mellitus without complications, bed confinement status, unspecified disorder of the skin and subcutaneous tissue, sepsis unspecified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-05-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen and food sanitation. 1. The facility failed to label and date all food items located in the reach in refrigerator and reach in freezer. 2. The facility failed to ensure all items stored in the reach in refrigerator and reach in freezers were sealed ensuring food contents were not exposed to air. 3. The facility failed to ensure dietary staff practiced proper hand hygiene and glove use. 4. The facility failed to ensure the blender and utensils were sanitized during food preparation. 5. The facility failed to dispose of expired items in dry storage. These failures could place residents at risk for food contamination and foodborne illness. Findings Included: During the initial tour of the kitchen on 04/29/24 at 10:04 AM the following was observed: 1. The reach in refrigerator contained sliced deli ham in a plastic bag that was torn open and exposed to air; singles cheddar cheese…
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 before2024-05-01 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 2 of 20 residents (Resident #26 and Resident #49) reviewed for resident rights; in that: The facility failed to ensure Resident #26 and Resident #49's call lights were within reach. This failure could place residents at risk of needs not being met. Findings included: Record review of Resident #26's admission record, dated 04/30/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #26 had diagnoses which included: type 2 diabetes mellitus (a chronic condition that affects the way the body processes the blood sugar), dysphagia (difficulty swallowing), acute kidney failure (condition in which the kidneys suddenly cannot filter waste from the blood), and hemiplegia (paralysis of one side of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-01 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 8 residents (Residents #17, #28 & # 44) reviewed for resident assessments. The facility failed to ensure Resident #17's two most recent MDS's reflected that Resident #17 received dialysis services. Resident #44's quarterly MDS incorrectly documented the resident as having an indwelling catheter. Resident #28's admission and Significant Change MDS's incorrectly documented the resident received dialysis services. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. Findings include: A record review of Resident #17's face sheet dated 04/30/24 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #17's diagnosis included hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal failure (high blood pressure makes it more likely that your kidney disease will get…
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 · D2024-05-01 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 60 (Resident #1) residents reviewed for dignity The facility failed to allow Resident #1 to assist with her daily showers. The facility failed to put undergarments on Resident #1 after changing. The facility failed to place clean linens on Resident #1's bed. This failure could place Resident#1 at risk for decreased quality of life, loss of dignity, self-worth and disrespected. Findings include: Review of Resident # 1's Face sheet dated 05/01/2024 revealed a [AGE] year-old female admitted on [DATE] with diagnosis that include Unspecified Osteoarthritis Unspecified Site (A progressive, degenerative joint disease, the most common form of arthritis, especially in older persons), Age-Related Osteoporosis without Current pathologic Fracture (A condition of reduced bone mass, with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-01 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 6 residents (Residents #44 & #163) reviewed for comprehensive care plans. Resident #44's care plan incorrectly documented the resident as having an indwelling catheter. The facility failed to ensure Resident #163's comprehensive care plan addressed Resident #163's full code advance directive. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings include: A record review of Resident #44's face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #44's diagnosis included muscle weakness (lack of physical or muscle…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-13 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect 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 observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, which included but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for one of one (Resident #1) resident reviewed for abuse and neglect. 1. The facility failed to ensure Resident #1 was properly assessed by a nurse when she was found sitting in the floor of her room and when she fell backwards. 2. The facility failed to ensure Resident #1 was not verbally or physically abused by CNAs . 3. The facility failed to ensure Resident #1's requests for assistance were not ignored. 4. The facility failed to ensure Resident #1 was safely transferred to her bed. 5. The facility failed to ensure when Resident #1 said she was in pain, the CNAs responded by getting a nurse to assess her. 6. The facility failed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-03-08 · 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 in the facility's only kitchen. 1.The facility failed to ensure food items in refrigerators, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best by', consume by or expiration dates. 3. The facility failed to ensure the ice machine vent/grate and outer surface was free from dust. 4. The facility failed to have Dietary staff wash hands or change gloves when they touched other surfaces while handling food or upon re-entering the kitchen. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observations of Reach-in Refrigerator #2 on 03/06/23 at 09:21 AM revealed the following:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-03-08 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for five (Residents #1, #12, #16, #36 and #70) of six residents reviewed for infection control. MA A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #1, #12, and #70. MA B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #16 and #36. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review on 03/07/23 of Resident #1's EHR revealed the resident was an [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including Hypertension, (elevated blood pressure), Atherosclerotic Heart Disease, (lack of adequate blood supply to the heart), and congestive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-06-15 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure residents were aware of where to locate the State Agency (SA) survey inspection results such as (surveys, certifications, and complaint/incident investigations) and post in a place readily accessible to residents, family members, and legal representatives of residents for 1 of 1 facility in that: The facility failed on 06/11/2025 to make a survey binder that was readily available and easily identified to all residents or the public that included survey results for viewing. This failure placed residents at risk of not being able to fully exercise their rights and at risk of not being aware of the facility's past deficiencies. Findings included: In an observation on 06/11/25 at 2:25PM of the facility's front door area, the receptionist desk, and the area near the administrative offices revealed there was no evidence of a survey results binder or notice of where to locate the binder. In a confidential interview on 06/11/2025 beginning at 2:00pm, eleven residents stated they did not know where or how to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$14,267 in federal fines across 1 penalty.
- $14,267 — penalty dated 2025-06-15
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| EASTLAND MEMORIAL HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/01/2021 |
| DAVIDSON, DAVID | Individual | W-2 MANAGING EMPLOYEE | — | since 05/01/2021 |
| MATTHEWS, TED | Individual | CORPORATE OFFICER | — | since 05/01/2021 |
| DHC OPCO-WACO, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2021 |
| COHEN, BRADFORD | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2021 |
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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 455670. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-15, 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 →
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