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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L1 |
| Actual harm | G1 | H· | I· |
| Potential harm | D39 | E34 | F10 |
| Minimal | A· | B· | C2 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| May 21, 2026 | Fire safety | Fire Safety Standard | 9 | Immediate jeopardy | — | Open → |
| May 21, 2026 | Health | Health Standard | 9 | Potential harm | — | Open → |
| Aug 22, 2025 | Health | Health Complaint | 4 | Potential harm | — | Open → |
| Jun 13, 2025 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Mar 14, 2025 | Fire safety | Fire Safety Standard | 8 | Potential harm | — | Open → |
| Mar 14, 2025 | Health | Health Standard | 17 | Potential harm | — | Open → |
| Feb 3, 2025 | Health | Health Complaint | 6 | Potential harm | — | Open → |
| Aug 23, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jul 11, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 22, 2024 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Apr 5, 2024 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Dec 8, 2023 | Fire safety | Fire Safety Standard | 1 | Potential harm | — | Open → |
| Dec 8, 2023 | Health | Health Complaint, Health Standard | 13 | Potential harm | — | Open → |
| Oct 14, 2023 | Health | Health Complaint | 8 | Actual harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| May 21, 2026 | Denial of payment for new admissions | — | Jun 23, 2026 · 13 days | 676283|Payment Denial|2026-06-23 |
| May 21, 2026 | Civil money penalty (fine) | $38,740 | — | 676283|Fine|139613 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L1 |
| Actual harm | G1 | H· | I· |
| Potential harm | D39 | E34 | F10 |
| Minimal | A· | B· | C2 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| May 21, 2026 | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies · Environment & life safety | L · Immediate jeopardy Widespread | Corrected Jul 6, 2026 | |
| May 21, 2026 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 6, 2026 | |
| May 21, 2026 | K-0345 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates 3 facilities.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Jose Burgos | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jul 1, 2026 |
| Michael Reese | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jul 1, 2026 |
| Franklin Ranch Healthcare LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2026 |
| Jose Burgos | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2026 |
| Soon Burnam | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2026 |
| Michael Reese | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2026 |
| Billie Haynes | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jul 1, 2026 |
| Chad Keetch | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Mar 1, 2011 |
| Ensign Services Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | May 7, 2026 |
| Franklin Ranch Healthcare LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Aug 4, 2026 |
| Haggerty Drive Health Holdings LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jul 1, 2026 |
| Standard Bearer Healthcare Op, LP | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jul 1, 2026 |
| The Ensign Group Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jul 1, 2026 |
| Jose Burgos | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jul 1, 2026 |
| Michael Reese | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jul 1, 2026 |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Legacy Nursing and Rehabilitation 2817 Kent Street, Bryan, TX 77802 CCN 455351 | 117 | Jul 9, 2026 | 411 harm | $8,044 | |
| Legacy Nursing and Rehabilitation 2202 N Travis Ave, Cameron, TX 76520 CCN 676174 | 104 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Avir at Patriot 11490 Gateway North Blvd, El Paso, TX 79934 CCN 676468 | 1.1 km | 124 | Aug 20, 2026 | 883 IJ1 harm | $109k | |
| Ambrosio Guillen Texas State Veterans Home 9650 Kenworthy St, El Paso, TX 79924 CCN 676060 | 5 km | 160 | Apr 9, 2026 | 46 | — | |
| Mountain Villa Nursing Home 2729 Porter Ave, El Paso, TX 79930 CCN 675768 | 14.7 km | 48 | Dec 4, 2025 | 52 | — | |
| White Acres Wellness & Rehabilitation 7304 Good Samaritan Court, El Paso, TX 79912 CCN 675025 | 16.4 km | 74 | Jun 16, 2026 | 49 | — | |
| Franklin Heights Nursing & Rehabilitation 223 S Resler Dr, El Paso, TX 79912 CCN 675479 | 16.6 km | 132 | Jul 1, 2026 | 865 IJ | $192k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 676283 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 676283 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety |
| F · Potential harm Widespread |
| Corrected Jul 6, 2026 |
| May 21, 2026 | K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 6, 2026 |
| May 21, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 6, 2026 |
| May 21, 2026 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 6, 2026 |
| May 21, 2026 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 6, 2026 |
| May 21, 2026 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 6, 2026 |
| May 21, 2026 | K-0922 | Meet requirements for the use and maintenance of medical gas equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 6, 2026 |
| May 21, 2026 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 12, 2026 |
| May 21, 2026 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 12, 2026 |
| May 21, 2026 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 12, 2026 |
| May 21, 2026 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 12, 2026 |
| May 21, 2026 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 12, 2026 |
| May 21, 2026 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jun 12, 2026 |
| May 21, 2026 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jun 12, 2026 |
| May 21, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jun 12, 2026 |
| May 21, 2026 | F-0940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Jun 12, 2026 |
| Aug 22, 2025 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 15, 2025 | Complaint |
| Aug 22, 2025 | F-0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 15, 2025 | Complaint |
| Aug 22, 2025 | F-0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 15, 2025 | Complaint |
| Aug 22, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 15, 2025 | Complaint |
| Jun 13, 2025 | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 7, 2025 | Complaint |
| Jun 13, 2025 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jul 7, 2025 | Complaint |
| Jun 13, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jul 7, 2025 | Complaint |
| Mar 14, 2025 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 4, 2025 |
| Mar 14, 2025 | E-0041 | Implement emergency and standby power systems. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 4, 2025 |
| Mar 14, 2025 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 4, 2025 |
| Mar 14, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 4, 2025 |
| Mar 14, 2025 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 4, 2025 |
| Mar 14, 2025 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 4, 2025 |
| Mar 14, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 4, 2025 |
| Mar 14, 2025 | K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 4, 2025 |
| Mar 14, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0791 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0850 | Hire a qualified full-time social worker in a facility with more than 120 beds. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0941 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0942 | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0943 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0945 | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0946 | Provide training in compliance and ethics. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Apr 14, 2025 |
| Mar 14, 2025 | F-0949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Apr 14, 2025 |
| Feb 3, 2025 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 3, 2025 | Complaint |
| Feb 3, 2025 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 3, 2025 | Complaint |
| Feb 3, 2025 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 3, 2025 | Complaint |
| Feb 3, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 3, 2025 | Complaint |
| Feb 3, 2025 | F-0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 3, 2025 | Complaint |
| Feb 3, 2025 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 3, 2025 | Complaint |
| Aug 23, 2024 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 13, 2024 | Complaint |
| Aug 23, 2024 | F-0850 | Hire a qualified full-time social worker in a facility with more than 120 beds. Administration Deficiencies · Administration & records | C · Minimal Widespread | Corrected Sep 13, 2024 | Complaint |
| Jul 11, 2024 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 12, 2024 | Complaint |
| May 22, 2024 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 7, 2024 | Complaint |
| May 22, 2024 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 7, 2024 | Complaint |
| May 22, 2024 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 7, 2024 | Complaint |
| Apr 5, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 19, 2024 | Complaint |
| Apr 5, 2024 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Past non-compliance Feb 21, 2024 | Complaint |
| Apr 5, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 19, 2024 | Complaint |
| Dec 8, 2023 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 5, 2024 |
| Dec 8, 2023 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 5, 2024 | Complaint |
| Dec 8, 2023 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 5, 2024 |
| Dec 8, 2023 | F-0563 | Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 5, 2024 | Complaint |
| Dec 8, 2023 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jan 5, 2024 | Complaint |
| Dec 8, 2023 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jan 5, 2024 | Complaint |
| Dec 8, 2023 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 5, 2024 | Complaint |
| Dec 8, 2023 | F-0693 | 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. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 5, 2024 | Complaint |
| Dec 8, 2023 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 5, 2024 | Complaint |
| Dec 8, 2023 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jan 5, 2024 | Complaint |
| Dec 8, 2023 | F-0758 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jan 5, 2024 | Complaint |
| Dec 8, 2023 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Jan 5, 2024 | Complaint |
| Dec 8, 2023 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Jan 5, 2024 | Complaint |
| Dec 8, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jan 5, 2024 | Complaint |
| Oct 14, 2023 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Nov 9, 2023 | Complaint |
| Oct 14, 2023 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 9, 2023 | Complaint |
| Oct 14, 2023 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 9, 2023 | Complaint |
| Oct 14, 2023 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 9, 2023 | Complaint |
| Oct 14, 2023 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Nov 9, 2023 | Complaint |
| Oct 14, 2023 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 9, 2023 | Complaint |
| Oct 14, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Nov 9, 2023 | Complaint |
| Oct 14, 2023 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected Nov 9, 2023 | Complaint |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.13 (case-mix index 1.43).
| Feb 12, 2026 |
25 |
| — |