No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Weslaco Nursing And Rehabilitation Center

422 E 18th St, Weslaco, TX 78596 · Non profit - Corporation · 120 certified beds · (956) 973-8451 Medicare & Medicaid certified

Call the home — (956) 973-8451 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Mar 2025Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (24% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • 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
  • a high number of inspection citations overall (26) — 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)

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.

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

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1015 S Utah Ave · (956) 969-1063 · Call to confirm hours
Pharmacy
1600 S Texas Blvd · (956) 854-2573 · Call to confirm hours
Grocery
1600 S Texas Blvd · (956) 854-2566 · Call to confirm hours
Park
E 18th St · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.7%15.8%15.4%better
Long-stay residents who lose too much weight3.2%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.3%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%2.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.5%3.3%3.3%better
Long-stay residents whose ability to walk worsened11.1%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.7%18.0%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers3.8%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control13.1%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.1%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication2.7%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine96.3%88.0%79.4%better
Short-stay residents rehospitalized after admission21.0%25.7%22.6%typical
Short-stay residents with an outpatient ER visit2.4%12.3%12.0%better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

63.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 85 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.4%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
46.4%U.S. median 56.6%
Met the expected recovery
0.43U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 46.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 56 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 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 32% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF63.4%CMS range 51.1–73.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 8.5–15.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge46.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge50.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge41.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.4%CMS range 3.4–12.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.17
RN hours/ resident / day
1.01
LPN hours/ resident / day
2.12
Aide hours/ resident / day
3.30
Total nurse hours/ resident / day
0.14
RN hoursweekends
23.8%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 120 beds and averages 113.1 residents a day — about 94% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.30 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.17 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 2.94 hrs/resident/day on weekends vs 3.45 on weekdays — 15% thinner on weekends. RN hours go from 0.19 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 24% is below the national median of 45%.

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

Inspection trend

6
deficiencies at the latest standard inspection (2025-05-14)
10
at the previous standard inspection (2024-03-14)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · Dcited before2026-04-24 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 4 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded in the MDS for use of a BiPAP device.This failure could place residents at risk of receiving care and services to meet their needs. The findings included:Record review of Resident #1's face sheet dated 4/23/26 reflected Resident #1 was admitted on [DATE] with an initial admission of 7/10/24. Resident #1 had a diagnosis of obstructive sleep apnea (a sleep disorder characterized by repeated episodes of complete or partial collapse of the upper airway, causing oxygen desaturation (decrease in oxygen level in the blood that falls below 90%) or sleep arousal) and hypertension (high blood pressure).Record review of Resident #1's quarterly MDS dated [DATE] indicated the following:, *Section C - Cognitive Patterns reflected Resident #1 had a BIMS of 14 which indicated a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #1) of 4 residents reviewed for care plans.1. The facility failed to ensure Resident #1's most current undated care plan reflected the use of grab bars.2. The facility failed to follow Resident #1's care plan when she was identified with scabbed over scratches on left wrist and did not report findings to MD/NP. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The Findings included:Record review of Resident #1's face sheet dated 4/23/26 reflected Resident #1 was admitted on [DATE] with an…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #2) of 5 residents reviewed for quality of care. The facility failed to perform a head-to-toe skin assessment immediately after finding a new skin tear on Resident #2 on 10/22/25. The failure could affect residents currently residing in the facility, resulting in not receiving needed care to maintain optimal health and placing them at risk for injury or deterioration in their condition. The findings included:Record review of Resident #2's face sheet, dated 11/13/25, reflected a [AGE] year-old female with an admission date of 12/06/24. Resident #2's pertinent diagnosis included Alzheimer's Disease (a progressive brain disorder that affects thinking, memory, and language, leading to a decline in the ability to perform daily activities). Record review of Resident #2's Quarterly MDS assessment, dated 10/02/25, reflected a BIMS…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-19 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from any significant medication errors for one of five residents (Resident #1) reviewed for medication errors. The facility failed to hold administration of Resident #1's nifedipine (blood pressure medication) when Resident #2's blood pressure was outside parameters on 10/01/25. This failure could place residents at risk for complications due to discomfort or their health being jeopardized.The findings include: Record review of Resident #1's face sheet, dated 10/13/25, reflected a [AGE] year-old female with an initial admission date of 07/10/23 and current admission date of 03/21/24. Resident #1's pertinent diagnosis included Essential Hypertension (high blood pressure with no known specific cause). Record review of Resident #1's Quarterly MDS assessment, dated 09/01/25, reflected a BIMS score of 12 which indicated moderate impairment. Record review of Resident #1's comprehensive care plan, dated 11/13/25, reflected 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-14 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 residents had the right to formulate an advance directive for 1 (Resident #262) of 8 residents reviewed for Advance Directives. The facility failed to ensure Resident #262's OOH-DNR was completed. The OOH-DNR form did not have the physician's signature. This failure could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes. The findings were: Record review of Resident #262's electronic face sheet dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her pertinent diagnoses included Syncope (fainting) and Collapse, Hypertensive urgency (high blood pressure), Nonrheumatic Mitral Valve Disorder (mitral valve does not close properly, allowing blood to flow backwards into the heart), Atrioventricular Block first degree (a condition where the hearts wiring was slow to send electrical signals), Paroxysmal Atrial…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-14 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #40) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #40 was coded in the MDS for a fall on 3/30/25. This failure could place residents at risk of receiving care and services to meet their needs. The findings included: Record review of Resident #40's face sheet dated 05/18/25 reflected Resident #40 was admitted on [DATE] and was [AGE] years old. Resident #40 had diagnoses of muscle wasting and atrophy (decrease or wasting of tissue, muscle or organs), lack of coordination, abnormalities of gait (pattern walking or moving on foot) and mobility, dementia (major neurocognitive disorder which causes a progressive decline in cognitive function, such as memory, thinking, reasoning, and judgment), and Alzheimer's disease (a type of dementia/neurodegenerative disease that affects the brain causing memory loss, confusion, and changes in…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-14 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 includes 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 (Resident #40 and Resident #23) of 8 residents reviewed for care plans, in that: 1.The facility failed to ensure Resident #40's most current undated care plan reflected his diagnosis of dementia. 2.The facility failed to develop a comprehensive person-centered care plan to address Resident #23's antibiotics for pneumonia. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The Findings included: 1. Record review of Resident #40's face sheet dated 05/18/25 reflected Resident #40 was admitted on [DATE] and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-14 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary 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 interview and record review the facility failed to ensure Seroquel had a proper diagnosis for 1 (Resident #50) of 1 residents reviewed for drug regimen review, in that: The facility failed to address Seroquel (antipsychotic) being given to a resident with diagnosis of dementia. This deficient practice could place residents at risk of receiving unnecessary medications and dosages. The findings were: Record review of Resident #50's face sheet dated 05/13/25 revealed an [AGE] year-old male initially admitted to the facility on [DATE] with the diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a diagnosis of dementia where the type and severity are unknown, and there are no significant psychological or behavioral symptoms like aggressiveness, agitation, or psychosis), Hallucinations (a perception that someone experiences as real, but that has no actual external stimulus). Record review of Resident #12's 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-14 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (200 hallway cart) of 4 medication carts. The facility failed to ensure expired supplies and medications were removed from the nurses' medication cart for 200 hall. The facility's failures could place residents receiving medication at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings included: During an observation on 05/13/2025 at 02:48 PM of the 200 hall nurse's medication cart with LVN A revealed 1 box of famotidine 10milligrams with an expiration date of 4/2025. During an interview on 5/13/25 at 8:00 a.m. LVN A stated all of the nurses were responsible for checking for expiration dates on the medications and supplies in the medication carts. LVN A stated using the expired medications and supplies could lead to the medications and topical treatments not being as effective. During an interview on 5/13/25 at 12:10 p.m. ADON C stated taking the medication…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-14 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 reviews, the facility failed to maintain effective pest control for 1 of 1 facility in that: The facility failed to have pest control effectively treat the facility for roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life. The findings include: During an observation on 05/13/2025 at 4:38 p.m., revealed a live roach on the floor in the hallway of the 400 hall. This observation was pointed out to LVN I, who immediately stepped on it, and walked away. Housekeeping staff swept the roach up. CNA J was charting in the hallway where the live roach came out. During an interview on 05/13/2025 at 4:40 p.m., CNA J stated that she has not seen roaches in the facility until now. She has not seen pest control, but she has heard that they do come in. During an interview on 05/13/2025 at 4:45 p.m., LVN I stated that she has not seen roaches in the facility that often. She stated that they have a pest…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Dcited before2025-03-31 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 interview and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 5 residents (Resident #1) reviewed for abuse/neglect. The facility failed to report an allegation of physical resident abuse by CNA B and CNA C of Resident #1 during a bed bath. This failure could place all residents at increased risk for potential abuse to unreported allegations of abuse and neglect. The findings included: Record review of Resident #1's admission Record dated 03/31/25, revealed a [AGE] year-old female, originally admitted to facility on 11/03/19. Resident #1's diagnoses included: Dementia (a group of thinking and social symptoms that interfere with daily functioning), chronic kidney disease (a condition characterized by a gradual decline in kidney function over a period of at least three…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-31 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 6 Residents (Resident #2) that were reviewed for infection control and transmission-based precautions policies and practices, in that: 1. CNA E failed to don the appropriate PPE before she entered Resident #2's room. These failures could place residents at risk for infection through cross-contamination of pathogens and infectious diseases. The findings include: 1. Record review of Resident #2's face sheet, dated 03/31/25, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: Heart failure, type 2 diabetes mellitus (high levels of sugar in blood), ESBL to urine (type of antibiotic resistance gene found in bacteria that can produce enzymes…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-14 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the physician acted upon and documented his or her rationale in the resident's medical record to the pharmacist report of any irregularities for 3 of 8 Residents (Resident #35, Resident #58, and Resident #87) whose records were reviewed for pharmacy services. 1.The facility failed to ensure the physician provided a rationale in response to the pharmacist recommendation to evaluate the effectiveness and continued use of Lorazepam (anti-anxiety), Hydroxyzine (antihistamine used to treat itching, anxiety, or sleepiness), and Clonazepam (treatment for seizures and panic disorder) for Resident #35. 2.The facility failed to ensure the physician provided a rationale in response to the pharmacist recommendation to evaluate the effectiveness and continued use of Omeprazole (treatment of gastroesophageal reflux disease) for Resident #58. 3.The facility failed to ensure the physician provided a rationale in response to the pharmacist recommendation 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-14 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days for one of eight residents (Resident #35) reviewed in that. The facility to continue to administer the psychotropic medication Lorazepam 0.5mg PRN after 14 days without an evaluation by the physician for continued treatment. This failure could result in residents receiving psychotropics that placed residents at risk of experiencing adverse drug reactions. The findings include: Record review of the physician order summary dated 03/13/24 for Resident #35 reflected resident was admitted on [DATE], was a [AGE] year-old female with diagnosis which included convulsions (a sudden, violent irregular movement), functional quadriplegia (loss of motor and/or sensory function), delusion disorders (mental illness, paranoia), tremors, anxiety…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards or food service safety for 1 of 1 kitchen reviewed for sanitation in that: The facility failed to remove 27 gallons of water that were past the use by date from their emergency drinking water supply. This failure could place residents at risk of foodborne illnesses. The findings included: In an observation of the kitchen on 03/11/2024 beginning at 9:10 a.m., revealed there were 27 gallons of water dated 01-11-23 and a use by date of 08/31/2023 stored in the back of the kitchen where the emergency water supply was stored. An interview on 03/13/2024 at 9:30 a.m., the Dietary Manage said the current emergency water supply had been there prior to her being hired. The Dietary Manager said she would remove the expired water gallons immediately and replace them with new ones. The Dietary Manger did not say if resident's could be negatively affected by drinking water past the use by date. An interview on 03/13/2024 at 4:30 p.m., 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-14 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 residents have the right to request, refuse, and or discontinue treatment and to formulate an advance directive for 2 (Resident #23 and Resident #61) of 11 residents whose records were reviewed for Out-of-Hospital Do-Not-Resuscitate Order forms in that:resident rights. The Facility did not ensure Resident #23 nor Resident #61's OOH-DNR form was completed fully and correctly. This failure could place residents at risk of not having their code status wishes met in the event they were needed. The findings included: 1.Record review of Resident #23's face sheet with an admission date of [DATE] reflected he was an [AGE] year-old male with diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes, and hypertension. Record review of Resident 23's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 15 which indicated Resident #23 was cognitive intact.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-14 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source were reported immediately to the State Survey Agency, within two hours, if the events that cause the allegation involve abuse or result in serious injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 1 residents ( Resident #49) of 4 residents reviewed. The facility failed to report within 24 hours, the allegations of resident abuse to the State Survey Agency for Resident #49. This failure could place all residents at increased risk for potential abuse and neglect due to unreported allegations of abuse and neglect. The findings included: Record review of Resident # 49's face sheet dated 03/14/2024 with an admission of 02/21/2018 and an initial admission date of 02/05/2017 reflected she was an [AGE] year-old female with diagnoses of 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0655 — isolated
    Create 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 observation, interview, and record review, the facility failed to implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 4 residents (Resident #268) reviewed for care plans, in that: The facility failed to address, in Resident #268 baseline care plan, her feeding assistance upon admission. This failure could affect all newly admitted residents to the facility by placing them at risk of not receiving the care and services for health promotion and continuity of care. The findings included: Record review of Resident #268's face sheet with an admission date of 03/09/2024 reflected she was a [AGE] year-old female with diagnoses of severe protein-calorie malnutrition (is a severe form of malnutrition), kyphosis (an abnormality of the spine causing excessive curvature of the upper back causing pain and stiffness), and adult failure to thrive ( a decline in…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition for 1 of 4 (Resident #268) residents reviewed for ADL care. The facility failed to ensure Resident #268 received assistance with eating. These failure placed residents at risk of poor nutrition, and weight loss. The findings included: Record review of Resident #268's face sheet with an admission date of 03/09/2024 reflected she was a [AGE] year-old female with diagnoses of severe protein-calorie malnutrition (is a severe form of malnutrition), kyphosis (an abnormality of the spine causing excessive curvature of the upper back causing pain and stiffness), and adult failure to thrive ( a decline in health and functional abilities, often accompanied by weight loss, muscle wasting, fatigue and decreased quality of life. It can affect appetite, social activities, memory, and daily functions). Record review of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided with professional standards of practice for 2 of 3 residents (Resident #36 and Resident #57) reviewed for quality of care in that: 1. The facility failed to ensure Resident #36's oxygen was administered at 5.0 Lpm via trach mask as ordered by physician. 2. The facility failed to ensure Resident #36's suctioning equipment was set up/connected at bedside ready for use. 3. The facility failed to ensure Resident #57's O2 saturation levels were monitored in percentage as ordered. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. The findings included: 1. Record review of Resident #36's admission Record dated 03/13/24 documented a [AGE] year-old female, on hospice, initially admitted on [DATE], readmitted on [DATE], with the diagnoses that included epilepsy with status epilepticus (A…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-14 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to ensure medications and biologicals were stored in locked compartments for one of eight residents (Resident # 50) reviewed for medication storage. The facility failed [NAME] prevent Resident #50 from having medication at his bedside for his personal use. This failure placed residents at risk of accidental and adverse medication reactions. Findings included: Record review of Resident #50's admission record dated 0/13/24 reflected Resident # 50 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included cirrhosis of liver (scarring of the liver by chronic liver diseases), and diabetes (sustained high sugar levels.) Record review of Resident #50's quarterly MDS assessment dated [DATE], reflected a BIMS score of 10 out of 15 which indicated moderately cognitive impairment (decisions poor; cues/supervision required.) Record review of Resident #50's comprehensive care plans dated 01/18/24, reflected…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain clinical records that were complete and/or accurate for one of eight (Resident #50) residents reviewed for clinical records in that: The facility failed to document in Resident #50's clinical chart that Resident #50 had family bring in medications for his personal use. This failure could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided. Finding included: Record review of Resident #50's admission record dated 0/13/24 reflected Resident # 50 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included cirrhosis of liver (scarring of the liver by chronic liver diseases), and diabetes (sustained high sugar levels.) Record review of Resident #50's quarterly MDS assessment dated [DATE], reflected a BIMS score of 10 out of 15 which indicated moderately cognitive impairment (decisions poor; cues/supervision…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-06 · tag F0577 — pattern
    Allow 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 and interview, the facility failed to ensure that the residents' right to view survey results were readily accessible to residents, family members and legal representatives of residents for 1 of 1 facility reviewed. The facility failed to retain any previous survey results dating back the last previous years 2019 -2022 within the survey binder for residents to review. This failure could place residents and visitors at risk of not being aware of the facility's past deficiencies. Findings included: Observation on 1/4/23 of the survey binder contained the last investigation dated 9/21/21. No other surveys or investigations dated after were found in binder. Record review of ASPEN Central Office revealed that last recertification survey was conducted on 10/21/21 and two other investigations thereafter dated 6/2022 and 1/2022 were conducted yet were not in found in survey binder. In an interview on 1/4/23 at 10:47 am the Administrator said he is the one in charge of updating the Survey Binder and said he could not tell why he had not updated it. In an interview on…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-01-06 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen, in that: The boxes of dry goods, bread, vegetables, and paper goods were placed directly on the floor in the pantry instead of on pallets. This deficient practice could place residents who received meals from the kitchen at risk of food-borne illness. The findings were: Observation during initial tour of the kitchen with the [NAME] on 01/03/23 at 9:15 AM revealed 14 boxes that included canned fruit and vegetables, sugar packets, flour, salt, and rice on the floor in the pantry. The [NAME] said the delivery from the food distributor had just arrived. Observation on 01/03/23 at 9:19 AM revealed the delivery driver from the food distributor had placed three more boxes of foam cups, plastic cutlery, and canned vegetables in the pantry. In an interview on 01/03/22 at 9:20 AM, the Delivery Driver said he had been given instructions by his supervisor to put the boxes on pallets, but he…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation record review and interview the facility failed appropriate treatment and services were received for 1 (Resident #100) of 6 residents with bowel and bladder incontinence, in that: The WCN did not perform hand hygiene between donning and doffing gloves when performing incontinent care for Resident #100. CNA A and the WCN did not use a clean technique or use clean wipes when performing pericare on Resident #100, wiping back to front. CNA A and CNA B did not wash their hands for a minimum of 20 seconds during pericare. This failure could place residents at risk for infections and cross contamination. The findings included: Record review of Resident #100's Face Sheet dated 01/06/23 reflected an [AGE] year-old female admitted to the facility on [DATE], diagnoses included: Pressure ulcer of sacral region (the portion of your spine between your lower back and tailbone), stage 3 (the sore has gone through all layers of skin into the fat tissue, exposing the resident to infection), aftercare…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-06 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral feeding received the appropriate treatment and services to prevent potential complications for two (Resident #61 and Resident # 45) of 3 residents reviewed with feeding tubes in that; 1)The facility did not ensure Resident #61's enteral feeding formula (fed through gastric tube) and water bag were not initialed, date and time started and name of formula and water bag for tube feeding were not labeled when first placed and as required by standard of care. 2) The facility did not ensure Resident #45's enteral feeding water bag was not initialed, dated, or timed when first placed and as required by standard of care. These failures could place residents with feeding tubes at risk for dehydration or calorie deficiency. Findings included: 1)Record review of the admission record for Resident # 61 dated 01/04/23 indicated Resident #61 was initially admitted on [DATE] and re-admitted on [DATE] with 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to WELLSENTIAL HEALTH — 67 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.7+1.3 vs chain
Health inspection 4 of 52.9+1.1 vs chain
Staffing 1 of 51.6-0.6 vs chain
Quality measures 5 of 54.2+0.8 vs chain
The other 66 homes this chain runs (chain average 2.7★, per CMS)
1 of 5Bastrop Lost Pines Nursing and Rehabilitation CentBastrop, TX 1 of 5Briarcliff Nursing and Rehabilitation CenterMcAllen, TX 1 of 5Brownsville Nursing and Rehabilitation CenterBrownsville, TX 1 of 5Fort Worth Transitional Care CenterFort Worth, TX 1 of 5Hidalgo Nursing and Rehabilitation CenterEdinburg, TX 1 of 5Houston Heights Nursing and Rehabilitation CenterHouston, TX 1 of 5Jefferson Nursing And Rehabilitation CenterBeaumont, TX 1 of 5Laredo West Nursing and Rehabilitation CenterLaredo, TX 1 of 5Lavaca Bay Nursing And Rehabilitation CenterPort Lavaca, TX 1 of 5Longview Hill Nursing and Rehabilitation CenterLongview, TX 1 of 5Spindletop Hill Nursing And Rehabilitation CenterBeaumont, TX 1 of 5Town and Country Nursing and Rehabilitation CenterBoerne, TX 1 of 5Wharton Nursing and Rehabilitation CenterWharton, TX 1 of 5Windsor Nursing And Rehabilitation Center Of RaymoRaymondville, TX 2 of 5Brenham Nursing and Rehabilitation CenterBrenham, TX 2 of 5Cityview Nursing and Rehabilitation CenterFort Worth, TX 2 of 5Corpus Christi Nursing And Rehabilitation CenterCorpus Christi, TX 2 of 5Edinburg Nursing and Rehabilitation CenterEdinburg, TX 2 of 5Elgin Nursing And Rehabilitation CenterElgin, TX 2 of 5Guadalupe Valley Nursing And Rehabilitation CenterSeguin, TX 2 of 5Hallettsville Nursing And Rehabilitation CenterHallettsville, TX 2 of 5Heritage Park Rehabilitation And Skilled Nursing CAustin, TX 2 of 5Live Oak Nursing and Rehabilitation CenterGeorge West, TX 2 of 5Maverick Nursing and Rehabilitation CenterEagle Pass, TX 2 of 5Memorial City Nursing and Rehabilitation CenterHouston, TX 2 of 5Robstown Nursing And Rehabilitation CenterRobstown, TX 2 of 5Southpark Meadows Nursing and Rehabilitation CenteAustin, TX 2 of 5Windsor AtriumHarlingen, TX 2 of 5Windsor Nursing And Rehabilitation Center Of SeguiSeguin, TX 2 of 5Windsor Nursing And Rehabilitation Center Of WeslaWeslaco, TX 2 of 5Windsor Nursing and Rehabilitation Center of AliceAlice, TX 2 of 5Windsor Nursing and Rehabilitation Center of BastrBastrop, TX 2 of 5Windsor Nursing and Rehabilitation Center of MorgaCorpus Christi, TX 2 of 5Yoakum Nursing And Rehabilitation CenterYoakum, TX 3 of 5Harlingen Nursing and Rehabilitation CenterHarlingen, TX 3 of 5Magnolia Crossing Nursing and Rehabilitation CenteHouston, TX 3 of 5Port Lavaca Nursing And Rehabilitation CenterPort Lavaca, TX 3 of 5The Woodlands Nursing And Rehabilitation CenterThe Woodlands, TX 3 of 5Val Verde Nursing And Rehabilitation CenterDel Rio, TX 3 of 5Windsor Mission OaksSan Antonio, TX

Showing 40 of 66; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
STARR COUNTY HOSPITAL DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 04/01/2017
REGENCY IHS OF WESLACO LLCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2017
CSV RHEA MANAGEMENT HOLDCO, LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 04/01/2017
DWD TX HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 04/01/2017
JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INCOrganizationINDIRECT OWNERSHIP INTERESTsince 04/01/2017
REG BRIDGE OPCO LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 04/01/2017
REG HG OPCO LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 04/01/2017
REG OPERATOR HOLDCO LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 04/01/2017
REGENCY INTEGRATED HEALTH SERVICES LLCOrganizationINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2017
REGENCY TEXAS HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 04/01/2017
BAIRD, DANIELIndividualMANAGING CONTROL - GOVERNING BODYsince 04/13/2021
CLAPP, BARBARAIndividualMANAGING CONTROL - GOVERNING BODYsince 06/01/2021
CORTESE, DARENIndividualMANAGING CONTROL - GOVERNING BODYsince 08/10/2021
GIBSON, PATRICIAIndividualMANAGING CONTROL - GOVERNING BODYsince 08/01/2021
GUERRA, ADRIANIndividualMANAGING CONTROL - GOVERNING BODYsince 05/01/2016
MANDELBAUM, ELLIOTIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2025
MUNOZ, THALIAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICERsince 01/01/1982
PENA, ELISAIndividualMANAGING CONTROL - GOVERNING BODYsince 05/01/2022
SALINAS, ARCADIOIndividualMANAGING CONTROL - GOVERNING BODYsince 09/17/2024
DEKOWSKI, DONOVANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2017
STRATTON-GROSCH, LESLIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/22/2024
422 EAST 18TH STREET LLCOrganizationADP OF THE SNFsince 04/01/2017
REGENCY IHS CLINICAL CONSULTING, LLCOrganizationADP OF THE SNFsince 01/01/2025
REGENCY IHS REHAB LLCOrganizationADP OF THE SNFsince 01/01/2025
BEJARANO, JOSEIndividualADP OF THE SNFsince 01/01/2025
SERNA, MARISSAIndividualADP OF THE SNFsince 01/01/2025
URESTE, LORENAIndividualADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 36 rows in the source record cover these 27 parties — each is shown once here with every role it holds. Nothing is omitted.

13 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$10.1M
Net patient revenuemost recent cost report
+3.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 73%Medicare 7%Other / private 21%

About 73% 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 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

$241per resident / day
operating cost
$7,323per month
≈ monthly operating cost
$249per day
avg. revenue, all payers

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

What families pay in TX

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676037. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-14, 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.

What to do next