Santa Fe Health & Rehabilitation Center
1205 Santa Fe Dr, Weatherford, TX 76086 · For profit - Corporation · 116 certified beds · (817) 594-2786 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- 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
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (60%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 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 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 23.3% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.0% | 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 | 0.7% | 2.4% | 6.5% | better 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 | 3.4% | 3.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 23.6% | 14.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 25.0% | 18.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.8% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.6% | 3.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 13.5% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.4% | 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 | 98.0% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.6% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.9% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.50 | 2.17 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.81 | 2.06 | 1.80 | typical |
‡ 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.
47.6% 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 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.2% 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 45 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 47.6%CMS range 33.8–64.2 | 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 | 10.3%CMS range 6.5–15.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 42.2% | 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 | 48.9% | 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 | 48.9% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 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 | 4.5% | 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 | 1.5% | 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 | 6.6%CMS range 3.4–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.31 | 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 116 beds and averages 88.0 residents a day — about 76% occupied, or roughly 28 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 2.89 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.75 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 2.47 hrs/resident/day on weekends vs 3.06 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.47 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% 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.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · E2026-05-07 · tag F0572 — patternGive residents a notice of rights, rules, services and charges.
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 inform residents, both orally and in writing in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility for 1 of 3 residents (Resident #1) reviewed for resident rights.The facility failed to maintain written acknowledgment that Residents #1 was informed prior to or at admission of their rights, the rules governing resident conduct, and their responsibilities during their stay at the facility This deficient practice could place residents at risk of not being aware of their rights, responsibilities, the facility's policies on admission.The findings included:Review Resident #1's face sheet, dated 03/10/26, revealed a [AGE] year-old female admitted on [DATE] with diagnoses of major depression (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-07 · tag F0580 — failed to tell family and doctor about changes — patternImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to immediately notify the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was an accident involving the resident for 1 of 2 residents (Resident #1) reviewed for resident rights. The facility failed to inform the Resident #1 responsible party (RP) that her depression medications were discontinued.The Findings:Observation and interview of Resident #1 revealed she was lying in bed. The resident was alert, oriented to name and place. She stated she did not know she was not receiving her major depression medication until the daughter informed her. She said the daughter felt her behavior changed and started asking questions about her medication. The Resident stated she did not have any interest in participating in activities because she was depressed.Record review of Resident #1 MAR for April 1 through 30, 2026 revealed the resident started receiving Lexapro oral tablet 20 mg by mouth in the morning on 04/01/26. Record review of Resident #1 MAR for May 1 through 7,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #4) reviewed for wound care. RN G failed to use standard, proper technique and process while providing wound care for Resident #4. RN G did not cleanse the wound before applying physician ordered treatment. These failures placed residents at risk for the spread of infection.Findings included: Review of Resident #4's face sheet, dated 04/15/26, revealed the resident was a 63- year- old female admitted to the facility on [DATE] with diagnoses of urinary tract infection, drug induced subacute dyskinesia ( characterized by involuntary movements primarily affecting the face, tongue, often associated with prolonged use of antipsychotic medications), intermittent explosive disorder (characterized by sudden episodes of unwarranted anger and violent outbursts)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-15 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments on 2 of 8 (Medication Cart 100 and Medication Cart 200) medication carts reviewed for pharmacy services.The facility did not ensure medication carts 100 and 200 were secured and locked when unattended.This failure could place all residents at risk of drug diversion.Findings included:During an observation and interview on 4/14/2026 at 6:28 AM, medication cart 200 was found unlocked and unattended against the wall of hall 200 beside the entrance into the dining room. DON was present in the hallway at that time. There were no other staff in the area. She locked the cart and stated LVN D was responsible for that medication cart. DON stated this failure could result in medications being taken by someone who is not supposed to have them potentially causing harm. During an observation on 4/14/2026 at about 6:55 AM, medication cart 100 was found unlocked with a drawer partially opened…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-15 · 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 control program designed to prevent the development and transmission of infection for 1 of 3 residents (Resident #86) observed for infection control.Facility staff (CNA-C) failed to sanitize, wash hands, and/or change gloves while providing perineal care to Resident #86.This failure could place all residents at risk of infectionFindings included:Record review of Resident #86's Electronic Face sheet dated 04/15/26 revealed he was a [AGE] year-old male. He was admitted to the facility on [DATE]. Diagnoses included: Hemiplegia (Paralysis) and hemiparesis (weakness) following Cerebral infarction (Stroke) affecting left non-dominant side, Depressive episodes, Type 2 Diabetes Mellitus with hyperglycemia (elevated blood glucose), Morbid obesity, Dysarthria (speech disorder) and anarthria (loss of ability to articulate) , Malignant neoplasm of duodenum (cancer of the small intestines), and Frontal lobe and executive function…
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 before2025-12-08 · 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. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 09/18/25, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including methicillin susceptible staphylococcus aureus infection (bacterial infection), methicillin resistant staphylococcus aureus (bacterial infection), constipation, bacteremia (presence of live bacteria in the bloodstream) and personal history of malignant neoplasm of breast (breast cancer). Review of Resident #1'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 · Ecited before2025-08-08 · 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 5 residents (Resident #5) reviewed for pharmaceutical services, in that: RN A failed to reorder medication for Resident #5 before his supply was depleted. These failures could place residents who receive medications at risk for a decline in health and of not receiving the intended therapeutic benefit of the medications. The findings included: Record review of Resident #5's face sheet dated 08/07/2025, revealed a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with the following diagnosis: diabetes mellitus with high blood sugar (a condition in which the is improper metabolism of carbohydrates resulting in too much sugar in the blood). Record review of Resident #5's admission MDS dated [DATE] revealed Section-C Cognitive Patterns Resident #5 had…
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 before2025-08-08 · 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 maintain medical records on each resident, in accordance with accepted professional standards and practices, which were complete and accurate for 1 of 5 (Resident #5) residents reviewed for resident records. RN A failed to ensure she documented treatment orders on the MAR or progress notes when not administered for Resident #5. This failure could place residents at risk of having errors with their care and treatment. Findings included: Record review of Resident #5's face sheet dated 08/07/2025, revealed a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with the following diagnoses: dermatitis (a condition in which the skin becomes red, swollen and sore, with small blisters forming caused from irritation or allergic reaction), diabetes mellitus with high blood sugar (a condition in which the is improper metabolism of carbohydrates resulting in too much sugar in the blood). Record review of Resident #5's physician orders…
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 before2025-02-21 · 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 observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerator and dry storage This failure could place residents that eat out of the kitchen at risk for foodborne illnesses. Findings include: During an observation of dry storage on 02/19/2025 at 09:10 AM revealed the following: *2 large plastic containers with label-powder milk with no use by date, *One bag of light brown in color, appeared to be crushed breadcrumbs sealed bag no label or date, *1 bag egg noodles in plastic zip bag with no used by date, *1 bag spaghetti noodles in plastic zip bag no used by date, *1 box lasagna noodles in plastic bag with no used by date, *1 bag vanilla wafers in zip lock with use by date 10/23, *8 packages vanilla wafers with no label or dates, *1 box powdered sugar open with no dates, *1 bag coconut flakes in a box with plastic bag not sealed or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-21 · tag F0576 — patternEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure that the residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the residents unopened for the entire facility reviewed for resident rights. The facility failed to ensure that residents received packages unopened. This failure could affect residents by placing them at risk of not receiving packages unopened that could result in residents experiencing diminished psychosocial well-being and quality of life. The findings included: During a confidential resident group meeting 02/19/25 at 02:13 PM, 10 confidential residents stated they had received mail and packages that had been opened by staff. They stated mailed was not delivered daily and there was no set schedule. They stated sometimes the mail was just placed in their rooms and they were not aware they had received a letter or a package. Residents stated they felt that it was a violation of their rights for their mail and packages to be opened and gone through. They stated no staff had…
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 9 citations
- Potential for harm · Ecited before2025-02-21 · 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
Based on observation, interview, and record review the facility failed to ensure pharmacy procedures were followed for 1 of 4(200 Hall Medication Cart) medication carts, and 2 of 2 medication refrigerators reviewed for pharmacy services. The facility failed to remove expired medications from the 200 Hall Medication Cart. The facility failed to document monitoring of temperatures in the medication storage refrigerators in the medication room. These failures could place residents at risk of receiving ineffective therapeutic doses. The findings include: An observation on 02/19/25 at 11:45 AM of the 200 Hall Medication Cart revealed that the bottom drawer contained a bottle of a liquid oral supplement that was marked as opened on 06/01/24 and expired 07/27/2024 per date on the bottom of the bottle per manufacturer. In an interview on 02/19/25 at 11:48 AM with RN A, who was using 200 Hall Medication Cart, stated that the bottle should have been checked and discarded way before now. She further stated there are no patients on 200 Hall at this time with orders for this supplement. She…
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 before2024-03-15 · 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
Based on observations, interviews, and record reviews, 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 diseases and infections for 3 of 3 staff (LVN-B, CNA-D, CNA-C) reviewed for infection control procedures. The facility failed to ensure the LVN-B perform proper hand hygiene before and after providing resident care. The facility failed to ensure the CNA-D perform proper hand hygiene before and after removal of gloves. The facility failed to ensure the CNA-C performed incontinent care in accordance with facility policy. These failures could place residents at risk for the transmission of communicable diseases. Findings included: During an observation and interview on 03/14/2024 at 9:33 a.m., LVN B was observed performing medication pass. LVN B went into resident's room to obtain blood pressure using wrist cuff and did not perform hand hygiene before or after leaving room. LVN B brought in a different wrist blood pressure cuff…
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 before2024-01-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services The facility failed to prevent the following: 1. Vinyl mesh liner was used to cover stainless steel surfaces on shelves and in drawers. 2. Floor tile grout was soiled with a dark colored build-up and dried food throughout the kitchen. 3. The interior surface of the microwave oven was soiled with dried food and grease. 4. The three-door freezer unit for storing breakfast foods and desserts had a temperature above zero and food items were not frozen solid. 5. The sink for the garbage disposal leaked and a bucket was on the floor beneath it to catch dripping water. 6. Floor tiles were missing near the dish machine. These failures could place residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may be contaminated. The findings included: Observations on 1/22/24 at 10:45 AM, during 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 · D2024-01-25 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's right to formulate an advance directive for 1 of 3 residents (Resident #44) reviewed for enactment of advance directives. The facility failed to ensure Resident #44 had the Out of Hospital Do Not Resuscitate (OOH-DNR) documentation in his electric record. This failure could put residents at risk of not having their OOH-DNR honored, resulting in receiving medical treatment they did not desire. The findings included: Record review of Resident #44's face sheet dated [DATE] revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the primary diagnosis of dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Record review of Resident #44's Care Plan, last revised on [DATE], revealed resident was a DNR. Record review of Resident #44's Physician Order Summary, dated [DATE], revealed the order DNR. Record review of Resident #44's electric record failed to have the Out of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · 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 the MDS assessment accurately reflected the resident's status for 1 of 2 residents (Resident #27) whose records were reviewed for resident assessment, in that: Resident #27 had a PASRR evaluation dated 2/18/2020 which documented he was positive for mental illness. His annual MDS assessment dated [DATE] documented he had no Level II PASRR conditions. This failure placed the resident at risk for not receiving mental health services as needed. The findings included: Review of Resident #27's admission Record, dated 1/24/2024, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: post-traumatic stress disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations); bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs - mania…
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 · D2024-01-25 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 2 residents (Resident #76) reviewed for PASRR Level 1 screenings. The facility did not correctly identify Resident #76 as having a mental illness and did not complete a new PASRR Level One Screening. This failure could place residents at risk of not being evaluated for PASRR services . The findings include: Record review of Resident #76's face sheet, dated 01/24/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #76's had admitting diagnosis of bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows). Record review of the Resident #76's admission MDS assessment, dated 11/19/2023, revealed resident had a BIMS score of 13, which indicated moderate cognitive impairment. Resident #76 had an active diagnosis…
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 · D2024-01-25 · 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, interviews, and record review, the facility failed to ensure that residents were free of a med error rate of 5% or greater (8%) for 2 (Residents #300 and #49) of 6 residents reviewed for medication administration. 1. The facility failed to ensure RN F primed (removing air bubbles from the needle to ensure that the needle is open and working) insulin pen for Resident #300 before administering Lantus insulin. 2. The facility failed to ensure RN G primed the insulin pen for Resident #49 before administering Novolog insulin. 3. The facility had a 8% medication error rate based on 2 errors out of 25 opportunities, which involved 2 of 6 residents reviewed for pharmacy services. This failure placed residents at risk of incorrect doses of medications. Findings included: 1. Resident #300 Record review of Resident #300 admission Record dated 01/25/24 revealed a [AGE] year-old female with admission date of 01/23/24. Resident had an active diagnosis list that included a Primary diagnosis of Diabetes…
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 before2024-01-25 · 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 maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 3 residents (Residents #14 and #66) whose record were reviewed for accurate and complete documentation. The facility failed to prevent the following: 1. The facility failed to ensure Resident #14's Out of Hospital - Do Not Resuscitate Order form was signed as by the resident and two witnesses in the box at the bottom of the form. 2. The facility failed to ensure Resident #66's Out of Hospital - Do Not Resuscitate Order form included a date for the physician's stamped signature, the physician's printed name, or the physician's license number. This failure could place residents at risk for discrepancies in the provision of necessary medical care and services and desired end-of-life decisions not being honored. The findings included: 1. Resident #14 Review of Resident #14's admission Record, dated 1/24/2024…
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 · C2026-04-15 · tag F0680 — widespreadEnsure the activities program is directed by a qualified professional.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to ensure that the activity program was directed by a qualified professional who completed a training course approved by the state for 1 of 1 (AD) activity director reviewed for training. The facility Activity Director (AD) failed to take her annual 8 hours of continuing education course work for Activity Director through the state AD training website. These failures could place residents at risk of inadequate activities from incompetent/untrained staff. The findings included:Record review of personnel files on 04/15/2026, revealed that the AD, with a hire date of 04/02/2023, did not receive/provide the facility with her 8-hour annual CE training.In an interview on 04/15/2026 at 4:25 PM AD stated she does not currently have her 8 CE hours for Activity director. She said she thought her {facility online training} hours from the facility trainings would cover those hours and was just told yesterday bherse CE credits did not count towards her AD continuing education hours. She stated she is currently searching for an online…
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 | 3 of 5 | 2.9 | +0.1 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 1 of 5 | 2.0 | -1.0 vs chain |
| Quality measures | 3 of 5 | 4.0 | -1.0 vs chain |
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 |
|---|---|---|---|---|
| PALO PINTO COUNTY HOSPITAL DISTRICT | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2014 |
| KORKMAS, ROSS | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 08/06/2019 |
| ADVANCED HCS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2014 |
| LICHTSCHEIN, TEDDY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2021 |
| SCHEINER, ELIEZER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2021 |
| SHELBY, JACK | 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.
About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 455957. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-15, 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 →
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.