Willow Park Rehabilitation And Care Center
300 Crowne Point Blvd, Willow Park, TX 76087 · For profit - Corporation · 125 certified beds · (817) 757-1200 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — 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 (28) — 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 (75%) 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 | 3 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 | 1 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.
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 | 25.3% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.3% | 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 | 2.9% | 2.4% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.6% | 3.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 16.8% | 14.0% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 34.7% | 18.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.1% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 9.7% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.0% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 59.4% | 88.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 21.7% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 16.9% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.20 | 2.17 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.27 | 2.06 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
48.9% 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 117 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 41.3% 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 46 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 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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 | 48.9%CMS range 40.9–56.7 | 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 | 10.1%CMS range 6.8–14.1 | 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 | 41.3% | 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 | 28.3% | 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 | 39.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 88.9% | 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 | 92.0% | 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 | 90.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.6% | 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 | 4.8% | 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 | 7.3%CMS range 3.8–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.07 | 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 125 beds and averages 91.9 residents a day — about 74% occupied, or roughly 33 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.29 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 3.19 hrs/resident/day on weekends vs 3.62 on weekdays — 12% thinner on weekends. RN hours go from 0.25 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 75% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · Fcited before2026-06-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services and 2 of 2 resident nourishment rooms reviewed for sanitary conditions.1. The facility failed to ensure a trash barrel containing raw egg shells and other waste was covered in the kitchen.2. The facility failed to ensure meat was not being thawed in a sink on the morning of 6/14/2026.3. The facility failed to ensure foods were in sealed containers and were labeled and dated in the walk-in refrigerator and the non-perishable food storage room on the morning of 6/14/2026.4. The facility failed to ensure dietary employees' food and drinks were not stored in a resident food refrigerator in the kitchen.5. The facility failed to ensure the floor drain cover was not removed with the open drain pipe exposed beneath the food preparation 2-compartment sink.6. The facility failed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-06-17 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet the residents' medical, nursing, mental, and psychosocial needs, for 9 of 18 residents (Residents #4, #5, #8, #9, #35, #46, #65, #69, and #77 ) reviewed for care plans.1.The facility did not develop and implement a comprehensive person-centered care plan to address Resident #4's hearing difficulty.2.The facility did not develop and implement a comprehensive person-centered care plan to address Resident #5's skin condition and skin tears.3.The facility did not develop and implement a comprehensive person-centered care plan to address Resident #8's assistance with activities of daily living, hearing loss, choices, walker and wheelchair use, limited range of motion, diagnoses, pain management, history of falls, swallowing difficulty, mechanically altered diet, no natural teeth, high risk medications, or therapy…
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 · E2026-06-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 5 of 7 residents (Residents #4, #7, #8, #69, and #72 ) reviewed for respiratory care. 1.The facility failed to ensure oxygen tubing for Residents #4, #7, #8, #69, and #72 was changed weekly, dated, and kept in a bag when not in use. 2.The facility failed to ensure Residents #7, #69, and #72's nebulizer masks were dated or kept in a bag while not in use.3.The facility failed to ensure Residents #4 and #7 had the needed liquid for proper humidification when oxygen was in use.These failures could place residents at risk for infections and transmission of communicable diseases. Findings included: Record review of Resident #4's face sheet, dated 6/17/2026, indicated a [AGE] year-old female, admitted to the facility 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.
- Potential for harm · D2026-06-17 · 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 interviews, observations and record reviews, the facility failed to ensure residents have the right to formulate an advanced directive for 1 (Resident #10) of 18 residents reviewed for advanced directives. 1. The facility failed to ensure that the electronic medical record dashboard and order reflected Resident # 10's wishes for DNR status. This deficient practice could place residents at risk of not having their wishes known and potentially receiving CPR during an emergency. Findings include: Record review of Resident # 10 reflected an [AGE] year-old female admitted to the facility on [DATE] and re-entered on [DATE]. Medical diagnosis include pulmonary fibrosis, type 2 diabetes, acute respiratory failure with hypoxia (deficiency of the amount of oxygen reaching the tissues), metabolic encephalopathy (a condition which causes brain dysfunction due to an underlying condition causing confusion, memory loss and possible loss of consciousness). Care plan dated [DATE] did not reflect her code status request…
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 · D2026-06-17 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents had the right to Privacy and Confidentiality of medical treatment and medical records for 2 of 24 residents care was reviewed.Based on observations, interviews, and record reviews, the facility failed to ensure that residents had the right to Privacy and Confidentiality of medical treatment and medical records for 2 of 24 (Resident #30, Resident #52) residents care was reviewed. Resident #30 and Resident #52 had handwritten signs placed in the view of residents, staff and visitors that revealed personal medical information. These failures could affect residents by contributing to poor self-esteem, lack of information, and unmet needs. Findings included: Resident #30Record review of Resident #30's face sheet dated 6/17/2026 revealed an [AGE] year old female with initial admission date of 3/17/2026 and readmission date of 4/15/2026 with diagnoses that included myasthenia gravis (a long-term neuromuscular junction…
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 · D2026-06-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 environment free accident hazards for 2 of 2 residents reviewed. Based on observation, interview, and record review the facility failed to environment free accident hazards for 2 of 2 (Resident #65 and Resident #30) reviewed for accident hazards in that:The facility failed to maintain an environment free from accident hazards for Resident #65 who had a sharp edge on broken bed remote in their room.The facility failed to maintain an environment free from accident hazards for Resident #30 who had a used syringe left on bedside nightstand in their room.These failures had the potential to result in injury and exposure to bloodborne pathogens.Findings include:Resident #65Record review of Resident #65's electronic face sheet dated 06/17/26 revealed he was a [AGE] year-old male. He admitted to the facility on [DATE] with diagnoses of: Parkinsons Disease (a progressive nervous system disorder affecting movement of the body), Mood disorder (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.
- Potential for harm · Dcited before2026-06-17 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 routine and emergency drugs and biologicals to its residents for 2 of 4 residents (Residents #7 and #77) reviewed for medication administration, in that:1. The facility failed to administer Resident #7's medications in a timely manner and withing the facility's medication window for administration on 6/15/2026, which included Keppra (a medication used to treat seizures), Midodrine (a medication used to treat low blood pressure), Eliquis (a blood thinning medication), Fludrocortisone Acetate (a medication used to treat low blood pressure), Loratadine (a medication used to treat allergies), Vitamin D3 (a medication used to treat muscle weakness), Lyrica (a medication used to treat nerve pain), and Potassium Chloride (a medication used to treat low potassium).2. The facility failed to administer Resident #77's medications in a timely manner and withing the facility's medication window for administration on 6/15/2026, which included…
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 · D2026-06-17 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure in accordance with State and Federal laws, drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 3 medication carts (Medication Carts Hall 300 and Hall 400) reviewed for medication storage. The facility failed to ensure medication carts were secured and locked.This failure could place residents at risk for drug diversion.Findings included:During an observation and interview on 06/14/2026 at 9:40 AM, LVN A was observed in a resident room and left Medication Cart for Hall 400 unlocked and unattended. LVN A stated she was an agency nurse and had only worked in the facility one time before that day. LVN A stated she typically locks the medication cart but just ran into the resident's room real quick. She stated she didn't know of a negative outcome because I never leave it unlocked.During an observation and interview on 06/15/2026 at 7:50 AM, at the Hall 300/400 Nurses station, a medication cart…
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 before2026-06-17 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview , and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #80) of three residents (Resident #80) reviewed for infection control practices.CNA M failed to perform proper hand hygiene including which included changing gloves while providing incontinence care to Resident #80 on 06/15/26.This failure could place residents at risk for the spread of infection. Findings Included: Record review of Resident #80's face sheet, dated 06//17/26, revealed a 79- year- old female who was admitted to the facility on [DATE]. Resident #80 had with diagnoses including which included full incontinence of feces, candidiasis (fungus) of skin and nail, pneumonia (lung infection) and constipation (lack of bowel movement). Record review of Resident 80's admission MDS assessment, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 one (Resident #1) of three residents reviewed for infection control practices. MA A failed to perform hand hygiene while administering medication to Resident #1 MA A stuck her bare hands into a pill bottle of buspirone 15 mg which contained multiple pills. These failures could affect the residents by placing them at risk for the spread of infection.Finding included:Review of Resident #1's face Sheet dated 01/13/26, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of acute respiratory failure, Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, behavior and is the most common cause of dementia), metabolic encephalopathy (a brain dysfunction caused…
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 18 citations
- Potential for harm · F2025-05-23 · tag F0919 — failed to provide a working call system — widespreadMake sure that a working call system is available in each resident's bathroom and bathing area.
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 it was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities for 2 of 2 nurse's stations (Hall 100/200 station and Hall 300/400 station). Resident's emergency call light was not audible at either the Hall 100/200 or Hall 300/400 nurse's stations. This failure placed residents at risk of not receiving timely care/assistance, falls, fall related injuries, head trauma, and hospitalization. Findings included: During observation on 5/23/25 at 5:00am, surveyor was standing at the nurse's station for Halls 100 and 200. Surveyor observed the call light outside of room [ROOM NUMBER] flashing but there was no audible sound at the nurse's station. Surveyor observed that at nurse's station for Halls 300 and 400 the call light system did not submit 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.
- Potential for harm · Dcited before2025-05-23 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #12 and Resident #13) of thirteen residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light was in reach and accessible for Resident #12 and Resident #13 on 05/22/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Review of Resident #12's Face Sheet, dated 5/22/25, reflected a [AGE] year-old female, admitted on [DATE]. Resident #12 had diagnoses of, Cerebral infarction (stroke), need for assistance with personal care, vascular dementia (reduced blood flow to brain), muscle wasting (loss of muscle mass). Review of Resident #12's Quarterly MDS Assessment, dated 5/11/25, reflected that Resident #12 had a BIMS score of 3, indicating severe cognitive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · 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 receives care to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable and a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #3) of 3 residents reviewed for pressure ulcers/wounds. The RN B failed to provide wound care for Resident #3's unstageable pressure ulcer to the right buttock and unstageable pressure ulcer to her right lateral foot on the date of 04/12/25. This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health. Findings included: Review of Resident # 3's electronic face sheet reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: leg fracture, dementia, and mild protein calorie…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-09 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for 2 of 15 employees (MM and CNA B) reviewed for employability. The facility failed to ensure record of criminal history check and/or an EMR/NAR check prior to offering employment were maintained. These findings placed residents at risk of receiving care by someone that was unemployable. The findings included: Record review of MM's employee file revealed a hire date of 07/22/2024 and no evidence of criminal history or an EMR check were completed prior to offering employment. Record review of CNA B's employee filed revealed a hire date of 08/08/2024 and no evidence of criminal history check or a NAR check were completed prior to offering employment. During an interview on 04/09/25 at 02:25 PM the DON stated she was not able to locate the criminal history and EMR/NAR check for MM and CNA B. The DON stated that there has been turn over in the HR position and does not know…
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 before2025-04-09 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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 follow the menu for 1 of 1 lunch meals observed. 1.The facility failed to ensure a sufficient amount of vegetables were prepared for residents on a regular diet. 2. The facility failed to ensure residents who were on a regular diet received vegetables that were not pureed. These failures could place residents at risk for dissatisfaction, poor intake, altered nutritional status, choking, and/or weight loss. The findings included: During an observation on 04/07/2025 at 11:00 AM the daily menu posted on wall outside of kitchen revealed: Lunch-Smothered Port Tips, Baby Baker, Fried Cabbage, Cornbread, Cookie, Beverage. During an observation of meal service on 04/07/2025 at 12:15 PM dietary staff ran out of regular cabbage for residents on a regular diet. The dietary staff served 3 resident's trays, who were on a regular diet, pureed cabbage. During an observation on 04/07/2025 at 12:36 PM the requested test tray did not have fried cabbage or pureed cabbage on the test tray. During an interview on 04/07/2025 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-09 · 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 observation, interview, and record review the facility failed to conduct an accurate assessment for 1 (Resident #47) of 18 residents reviewed for assessments. The Facility failed to ensure Resident # 47 most recent MDS dated [DATE] was accurately completed with Resident's hospice status, who was receiving hospice care. These failures could place residents at risk by decreasing the accurate information available to determine the care and services needed for each resident. The findings included: Record review of Resident # 47's face sheet dated 04/09/2025 revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses heart failure, high blood pressure, and chronic kidney disease. Record review of Resident #47's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Pattern- Resident had a BIMS of 7, meaning moderate cognitive impairment; Section O- Special Treatments, Procedures, and Programs revealed no evidence Resident #47 received hospice care. Record review of Resident #47's most…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-09 · 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 interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 18 residents (Resident #74) reviewed for accuracy of records, in that: The facility failed to document in Resident #74's weekly skin assessment dated [DATE], that Resident #74 had a pressure ulcer to her right buttocks discovered on 04/02/25. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care. The findings included: Review of Resident #74's electronic face sheet reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: leg fracture, dementia, and malnutrition. Review of Resident #74's admission MDS assessment dated [DATE] reflected Resident #74 had a BIMS score of 04 indicating severe cognitive impairment. Further review of Section M reflected resident was at risk for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-29 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide services with reasonable accommodation of needs for 1 (Resident #3) of 10 residents reviewed for resident call system. The facility failed to provide a working communication system on 10/01/2024 that was easily at reach and that would allow Resident #3 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living. The findings included: Record review of Resident #3's face sheet dated 10/03/2024, revealed: an [AGE] year-old-female admitted on [DATE], with the following diagnosis Hemiplegia and Hemiparesis following Cerebral infraction right dominant side(weakness and paralysis to right side due to stroke), Atrial Fibrillation(irregular heart rate), Type 2 Diabetes, lack of coordination, . Record review of Resident #3's Quarterly MDS dated [DATE] revealed the following: *Section C-…
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 · D2024-10-29 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for 1 (Resident #1) of 4 residents reviewed for discharge requirements. The facility failed to ensure Resident #1 was provided a discharge in writing with appropriate reason for the necessity of discharge. This failure placed residents at risk of not receiving necessary care and services. Findings included: Record Review of Resident #1's Face Sheet dated 10/03/2024, revealed a [AGE] year-old male, admitted to the facility on [DATE], discharged on 09/25/2024 with the following diagnoses Insomnia, Intellectual Disabilities and Depression. Record review of Resident #1's admission MDS dated [DATE] revealed: Section C- Cognitive Patterns Resident #1 had a BIMS score of 5, meaning severe cognitive impairment. Record review of Resident #1's progress notes revealed the following: *09/25/2024 at 8:15 AM written by LVN…
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 · D2024-10-29 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmission for one of four residents (Resident #1) reviewed for discharge planning. 1. The facility failed to implement discharge plan for Resident #1 who was admitted on [DATE] until the day he was discharged on 09/25/2024 . 2. The facility failed to notify the Ombudsman of Resident #1's discharge. 3. The facility failed to notify Resident #1's physician of the discharge. These failures could place residents at risk of not having their care needs addressed after discharge. Findings include: Record review of Resident #1's face sheet, dated 10/18/24, reflected 59 years-old male who was admitted to the facility on [DATE]. Record review of Resident #1's physician's admission notes, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-02-15 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the planned menus were followed and prepared according to the weekly menu for 3 of 4 supper meals planned during the 4 day survey time frame. A menu substitution was hand-written on the Week at a Glance Fall / Winter Menu 2023 -2024, Week 1 for Monday's 2/12/24 supper meal. The substitution was not recorded on the Menu Substitution Sheet. The Week at a Glance Fall / Winter Menu 2023 -2024, Week 1 for Wednesday's 2/14/24 supper meal was partially substituted with the menu for Thursday's 2/15/24 supper meal due to the main entrée of chicken and dumplings not being prepared according to the planned menu for 2/14/24. This failure placed the residents at risk for not receiving meals adequate to meet their nutritional needs and a decline in nutritional health status. The findings included: Review of the Week at a Glance - Fall / Winter Menu 2023-2024, Week 1, revealed a hand-written substitution at the bottom of the page for the Monday…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-15 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 serve food at safe and appetizing temperatures during observation of the preparation of one of one meal. The planned Wednesday supper menu for 2/14/24 was substituted and potato salad and sliced red beets were not prepared in advance to ensure they were served at 41 degrees F or below. This failure placed residents at risk for receiving food that was not at a palatable temperature and foodborne illness. The finding included: Review of the Week at a Glance - Fall / Winter Menu 2023-2024, Week 1, revealed the following planned menus: Wednesday Supper (2/14/24): chicken and dumplings; tossed salad with dressing; cornbread with margarine; warm iced cinnamon roll; milk; beverage of choice; water. Thursday Supper (2/15/24): BBQ riblette; potato salad; fried okra; blushing pears; bread slice with margarine; milk; beverage of choice; water. Review of the Menu Substitution Sheet Sample Form revealed entries for the scheduled food item, substitute, reason for substitution, and employee signature, dated 2/14/24 as…
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 before2024-02-15 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
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 top exterior surface of the ice machine was soiled with dust build-up and had a plastic ice scoop on it without being in a protective holder. A stainless steel shelf was soiled with spilled spices. Cooking utensils and pans were suspended in the air from a frame and their sanitized food surfaces were exposed to the air. The nonperishable food storage room had a bulk storage container with brown sugar with a plastic scoop in it and an opened package of waffle mix had been placed in a resealable plastic bag but was not labeled or dated. The door to the walk-in refrigerator was left open during the evening meal preparation on 2/14/24. The dishwasher machine temperature log had water temperatures and sanitizer level recorded prior to being measured on 2/14/24. This failure placed residents at risk for decline in nutritional health status and foodborne illness. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-15 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set assessments accurately reflected the residents' status for 2 of 4 residents (Residents #2 and #14) whose records were reviewed for accurate assessment of nutritional status, in that: 1- Resident #2 had a significant weight loss of 12.86 % in a 6-month time frame, going from 171 pounds during July 2023 to 149 pounds during January 2024. Resident #2's annual MDS assessment, dated 7/20/2023 documented a weight of 171 pounds, and the quarterly MDS assessment, dated 1/01/2024 documented a weight of 149 pounds with no weight loss of 10% or more during the past 6 months. 2- Resident #14 had a significant weight loss of 14.29% in a 5-month time frame, going from 157.5 pounds during August 2023 to 135 pounds during January 2024. Resident #14's annual MDS assessment, dated 01/12/2024 documented a weight of 135 pounds with no weight loss of 10% or more during the past 6 months. This failure placed the residents at risk for significant…
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 · D2024-02-15 · tag F0646 — isolatedNotify the appropriate authorities when residents with MD or ID services has a significant change in condition.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to notify the state mental health authority promptly after a significant change in the mental condition for 1 of 8 residents (Resident #51) reviewed for mental illness, intellectual disability, or developmental disability. The facility failed to complete a PL1 with addendum form -1012 when Resident # 51 received a new diagnosis for Bi-Polar Disorder, current episode manic severe with Psychotic features added on 11/18/2023. This failure placed resident at risk of mental health needs not being met. The findings included: A record review of Resident # 51's face sheet dated 2/14/24 revealed initial admission was 6/26/23. A diagnosis list that included Bipolar Disorder, Current Episode Manic Severe with Psychotic Features (diagnosis date 10/20/23). A record review of PASARR Level 1 (PL1) screening, dated 6/26/23, indicated Resident # 51 had no indication of mental illness. No PASARR Level II (PE) Screening or Form-1012 (mental illness/Dementia Resident Review) was found in the clinical record. A record review of Resident #51'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 · D2024-02-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 of 2 residents (Resident #57) reviewed for ADLs. The facility failed to provide showers consistently for Resident #57. This failure could place residents at risk for poor personal hygiene and a decline in their quality of life and health status. Findings included: Record review of Resident #57's Face Sheet, dated 02/15/24 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a latest return date of 10/26/23 with the following diagnoses: cerebral infarction (stroke), contracture of muscle (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.) of right shoulder, right upper arm, right forearm, right hand and left hand. Review of Resident #57's quarterly MDS dated [DATE] revealed the resident was admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-07 · 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 , interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate accountability of controlled drugs on 4 of 4 medication carts. The Change-of-Shift Record of Control Substance Log for the 100/200, 400/500 medication carts were missing signatures. These failures could place residents receiving medications in the facility at risk for a drug diversion. The findings include: Record Review on 9/6/23 revealed nurses were in serviced on narcotic audit results training, drug diversion, narcotic Count, and med administration on 6/21/23. Record review on 9/6/23 of the Control Card Count revealed the sheets were missing signatures on the following dates and shifts.: September 2023 Cart 200- 9/2 2 PM - 10 PM on coming and off going shifts signatures missing; 9/6 6 AM - 2 PM on coming shift signatures missing Cart 100 - 9/1 10 PM - 6 AM on coming signatures missing. Cart100/200 9/3 6 Am - 2 PM on coming nurse signature missing and 2 PM - 10 PM on coming and off going nurse signatures missing. August 2023…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-10-29 · tag F0732 — patternPost nurse staffing information every day.
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 staffing information was posted in a prominent place readily accessible to residents and visitors that included: The total number and the actual hours worked by the registered nurses, licensed practical nurses or licensed vocational nurses and certified nurse aides directly responsible for resident care per shift for 21 of 21 days reviewed for required postings. The facility failed to ensure the daily staffing information was posted in a prominent location on 10/02/2024. This failure could place residents, their families, and visitors at risk of not knowing how many staff are currently working to provide care on all shifts. Findings Included: During an observation on 10/02/2024 at 11:40 AM, the daily staffing posted in hallways was dated 09/11/2024. During an interview on 10/02/2024 at 11:45 AM, the DON stated her expectation was that the daily staffing be posted daily. The DON stated a previous employee was responsible for posting the daily staffing and when she left, she had not realized that it was not being…
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 NEXION HEALTH — 51 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 | 2 of 5 | 2.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 2.3 | +0.7 vs chain |
| Staffing | 1 of 5 | 2.8 | -1.8 vs chain |
| Quality measures | 3 of 5 | 2.6 | +0.4 vs chain |
The other 50 homes this chain runs (chain average 2.2★, per CMS)
Showing 40 of 50; 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PARKER COUNTY HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/01/2026 |
| NILES, RICHARD | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2026 |
| WIMMER, CALVIN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2026 |
| BACUS, RANDY | Individual | CORPORATE OFFICER | — | since 05/01/2026 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | — | since 05/01/2026 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | — | since 03/01/2011 |
| HOME RIVER HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/28/2026 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | — | since 02/13/2026 |
| RETAMA PKWY HEALTH HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 05/01/2026 |
| STANDARD BEARER HEALTHCARE OP, LP | Organization | ADP OF THE SNF | — | since 05/01/2026 |
| THE ENSIGN GROUP INC | Organization | ADP OF THE SNF | — | since 05/01/2026 |
CMS files one row per role, so the 16 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676365. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-17, 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.