4306 24th St., Lubbock, TX 79410 · Lubbock County · (806) 793-2555
93 certified beds, about 59 residents a day · For profit - Corporation · Medicare and Medicaid since 1992
CMS Care Compare ratings, data as of September 1, 2026 · CCN 675093 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on June 25, 2026, inspectors cited 16 health deficiencies (the Texas average is 9.4, the national average 9.2).
Of 50 health citations since January 2024, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $8,994 in the last three years; the largest was $8,994, and the latest is dated January 17, 2024.
Nurses and nurse aides worked 3.13 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.21 of those hours.
82.2% of nursing staff left within the year CMS measured (Texas average 55.3%).
CMS links it to Skyblue Healthcare, an affiliated group of 12 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 50 health citations on file.
Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 3 of 22 residents (Residents #4, #42 and #45) reviewed for advanced directives. The facility failed to ensure Residents #4, #42 and #45, who were listed as a DNR (Do Not Resuscitate), had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that did not have missing required information. These failures could place residents at risk of not having their end-of-life wishes honored and incomplete records.
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide comfortable and safe temperature levels for 1 of 1 dining rooms and 1 of 2 Halls (Hall 2) and a clean and comfortable environment for the 1 of 3 Hallways (front hallway). The facility failed to ensure the temperature for the dining room and Hall 2 did not go above 81 degrees Fahrenheit. The facility failed to ensure the front hallway did not have sticky handrails or a clean appearance on the walls and doors. These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles and stored in locked compartments for 2 of 4 carts (Station 1 Treatment Cart, and Station 2 Nurse Aide Medication Cart) reviewed for medication storage. 1. LVN F failed to ensure the Station 1 Treatment Cart was secured when unattended. 2. MA D failed to ensure the Station 2 Medication Aide Cart did not contain loose pills. These failures could place residents at risk of not receiving prescribed medications as ordered, having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversion.1. During an observation on 06/23/2026 at 2:26 PM, the treatment cart was in front of the business office unlocked and unattended. [...]
Inspectors wroteBased 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 safety. -The facility failed to ensure foods were properly stored in the refrigerator, freezer and pantry.-The facility failed to ensure the food preparation table, ice chest, walls and fire extinguisher were cleaned. These failures could place residents at risk for food contamination and foodborne illness.
Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters (dumpsters #1 and #2) and 1 of 1 (Oil Container #1) oil disposal container, in that:The door for dumpster #1 was left open. Dumpster #2 had no plug and was leaking an unidentified substance on the concrete. There was an unidentified substance build-up on top of the oil container #1 and the lid was opened. These failures could place residents at risk of exposure to germs and diseases carried by vermin and rodents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in the 1 of 1 kitchen, 1 of 1 dining room, 1 of 2 common areas and 1 of 3 Halls (Hall 2) reviewed for physical environment. The facility failed to provide an effective pest control program for flies in the facility. This failure could place residents at risk for vector-borne diseases.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 18 residents (Resident #59) and 1 of 1 smoking area reviewed for smoking. The facility failed to follow the smoking policy and ensure Resident #59 had a safe smoking evaluation completed. The facility failed to follow smoking policy allowing residents to smoke in non-designated smoking areas. This failure could place residents at risk of an unsafe smoking environment and an increased risk of injury related to smoking.
Inspectors wroteBased on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days for 2 of 22 resident (Resident #6 and #45) reviewed for PRN psychotropic medications, in that: Resident #6 continued to have a PRN order for Lorazepam 2 MG/ML after 14 days without a stop date. Resident #45 continued to have a PRN order for Lorazepam 1 MG after 14 days without a stop date. This failure could result in residents receiving antipsychotic medications when contraindicated and could result in residents experiencing adverse drug reactions.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 18 residents (Resident #59) reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #59 for tobacco use on his annual MDS assessment. This failure could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 18 residents (Resident #59) reviewed for care plans. The facility failed to develop a care plan for Resident #59 related to smoking. This failure could place residents at risk of not receiving the care required to meet their individual needs.
Inspectors wroteBased on interviews and record reviews, the facility failed to review and revise the person-centered, comprehensive care plan for 2 (Resident #43 and Resident #49) of 22 residents reviewed for comprehensive care plan revisions.1. The facility failed to ensure Resident #43's comprehensive care plan was updated with the most current information for the resident's smoking status. 2. The facility failed to ensure Resident #49's comprehensive care plan was updated with the most current information for the resident's smoking status. These failures could put residents at risk of not receiving the appropriate care, services, or treatments needed to maintain health.1. Record review of the admission record for Resident #43, dated 06/23/2026 revealed a [AGE] year-old female with an original admission date of 01/16/2022. Resident #43 had diagnoses which included: [...]
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #49) reviewed for smoking. The facility failed to ensure Resident #49's smoking items were kept at the nursing station and he received adequate supervision while smoking. This failure could place the residents at risk of inadequate supervision, accidents, and burns which could result in injury. Findings Included: Record review of the admission record for Resident #49, dated 06/24/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: urinary tract infection (bacteria in urinary system), muscle weakness, and other lack of coordination. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 2 residents fed by gastrostomy tube (g-tube) (Resident #42), in that: The facility failed to ensure Resident #42's feeding pump was hooked up and infusing at the time ordered by the physician. This failure could result in weight loss and dehydration in residents with a g-tube.
Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 22 residents reviewed for unnecessary medication (Resident #10). The facility did not monitor Resident #10 for side effects of the anticoagulation medication Apixaban. This failure could place the residents at risk for adverse consequences of medication.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 10.34 percent based on 3 errors out of 29 opportunities, which involved 2 (Resident #8 and Resident #43) of 3 residents reviewed for medication administration. 1. MA E failed to give Resident #43's dose of the medication Chlorhexidine Gluconate at the ordered time, due to not having the medication available, resulting in a missed dose. 2. MA E failed to give Resident #8's doses of the medications Apixaban and Propranolol Hydrochloride at the ordered time, resulting in a late dose for each medication. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and a decline in health.1. [...]
Inspectors wroteBased 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 and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #42) reviewed for infection control. RN A failed to wear proper PPE (a gown) when providing wound care and administering tube feeding through a PEG tube) for Resident #42 who was on EBP. These failures could place residents at risk for the spread of infection and cross contamination. Record review of Resident #42's admission record dated 06/25/2026, revealed a [AGE] year-old male with an original admission date of 07/16/2012. Resident #42 had diagnoses which included: [...]
Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of all medications to meet the needs of the residents and establishes a system of records of receipt and disposition of all drugs in sufficient detail to enable an accurate reconciliation for 1 of 1 resident reviewed for pharmaceutical services in that: The facility failed to have a system in place to ensure proper reconciliation of medications that would prevent missing medications for Resident #1. This failure could place residents at risk of having their medications diverted and/or receiving the incorrect dosage because due to staff not counting mediations in the narcotics refrigerator.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident's bedside, toilet, and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff area for 1 of 5 residents (Resident #2 ) reviewed for resident call system. The facility failed to ensure Resident #2's call light was within reach while he was positioned in his bed. This failure could place residents at risk of not being able to call for assistance in emergency situations, a delay in care and services, and increased risk of falls and/or injuries.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise, for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to implement interventions to ensure that Resident #1 did not have a significant weight loss of 16.8 pounds, a 10% body weight loss, between 12/03/2026 and 01/16/2026. This failure could place residents at risk for decreased nutritional status, malnutrition, and a decline in health. Record review of Resident #1's face sheet dated 02/04/26 reflected an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses which included: [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the resident's free of physical and chemical restraints that were not medically indicated for 1 of 15 residents (Resident #1) observed for physical restraints in that; The facility failed to ensure Resident #1 had a physician order, consent and evaluation for a chest restraint used for positioning and mobility. This failure could place residents at risk of injuries or entrapment.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure allegations of abuse were promptly and thoroughly investigated for 7 of 14 residents (Resident #1, #3, #4, #6, #8, #9, and #12) reviewed for abuse prevention. 1) Resident #1 alleged the Administrator made an obscene hand gesture. Resident #1 was not interviewed regarding the allegation and the incident was not reported to the State Agency as required. 2) Residents #3, #4, #6, #8, #9, and #12 alleged staff members were rude and/or yelled at them. The residents' allegations were documented on the Safe Surveys conducted on 05/08/25, the facility did not initiate an investigation on any of the residents' statements. These failures placed all the residents at risk for abuse and psychological harm, which resulted in substandard quality of care.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure dignity was maintained for 1 of 14 residents (Resident #1) reviewed for respect and dignity. The Administrator failed to respect and ensure Resident #1's dignity when he made an obscene hand gesture towards the resident. This failure placed residents at risk for loss of self-worth and emotional distress and failed to ensure the residents' right to be treated with dignity and respect.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure an allegation of abuse was reported immediately to the State Agency as required for 1 of 14 residents (Resident #1) reviewed for abuse reporting. Resident #1 alleged the Administrator made an obscene hand gesture. The allegation was not reported to the State Agency. This failure resulted in the residents' right to be free from abuse not protected, eliminated the opportunity for a timely investigation by the State Agency and placed all the residents at risk for abuse and psychological harm, which resulted in substandard quality of care. Record review of Resident #1's Transfer/Discharge Report dated 08/27/25 reflected the [AGE] year-old male resident was re-admitted to the facility on [DATE] with a diagnosis of paraplegia. [...]
Inspectors wroteBased on interview, observation, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for narcotic medication being accounted for. 1. LVN A failed to document Resident #1's Oxycodone/Acetaminophen 10/325MG on the MAR after administration. 2. LVN B & RN C failed to document Resident #1's Oxycodone/Acetaminophen 10/325MG on the Narcotic Record Count Sheet after administration. 3. LVN B failed to notify the DON of a discrepancy with Resident #1's Oxycodone/Acetaminophen 10/325MG per facility policy. These failures could place residents at risk for not receiving prescribed medication.
Inspectors wroteBased on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #1) reviewed for care plans. Resident #1 did not have a care plan for Cognitive Loss/Dementia, Communication, Urinary Incontinence, Behavioral Symptoms, and Pressure Ulcers. Resident #1's care plan also did not include the physician's order for a wander guard or why the wander guard was ordered. Resident #1 did not have a care plan for her behaviors related to her diagnoses. This failure could place residents at risk of not receiving the care required to meet their individualized needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 9 of 15 confidential residents. The facility failed to ensure 9 of 15 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information in regard to who the facility grievance officer was, their contact information, and how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, as well as describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 18 residents (Residents #23 and #36) reviewed for care plans in that: The facility failed to ensure that Resident #23's care plan was revised, updated, and individualized with interventions and goals to address Resident #23's vison. The facility failed to ensure that Resident #36's care plan was revised, updated, and individualized with interventions and goals to address Resident #36's vision, activities, and pressure ulcers. [...]
Inspectors wroteResident #29 Care Planning 04/09/25 02:41 PM record review shows discrepancies' with several of the care plan not being care planned. 04/10/25 12:26 PM It was determined that resident had several triggered MDS items that were not care planned. Resident #40 Care Planning 04/10/25 12:25 PM It was determined that resident had several triggered MDS items that were not care planned.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal (lunch meal) reviewed for palatability, attractiveness, and appetizing. The facility failed to ensure foods were at appropriate temperatures. The facility failed to ensure proper handwashing during preparation of foods. The facility failed to provide edible (unburnt) food to residents. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and food borne illnesses.
Inspectors wroteBased 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 and to help prevent the development and transmission of communicable diseases and infections for 6 of 10 residents (Residents #41, #32, #98, #38, #195, #40) reviewed for infection control. 1. MA A failed to sanitize the blood pressure cuff between resident use for Resident #41 and Resident #32. 2. MA A failed to sanitize the blood pressure cuff between resident use for Resident #32 and Resident #98. 3. MA A failed to sanitize the blood pressure cuff between resident use for Resident #98 and Resident #38. 4. CNA C failed to utilize hand hygiene between glove changes during incontinence care with Resident #195. 5. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for Quality of Care. The facility failed to transfer Resident #1 to bed on 03/03/25 resulting in him staying up in his wheelchair until the following morning (03/04/25). These failures could place residents at risk of not receiving necessary care or appropriate transfer.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 Residents (Resident #1) reviewed for catheter care in that: The facility failed to ensure Resident #1 had physician orders for a urinary catheter. This failure had the potential to affect residents by placing them at an increased risk of not receiving the appropriate care or services related to the urinary catheter.
Inspectors wroteBased on obervation, interviews and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administration of drugs that meet the needs of all residents for 1 of 5 residents (Resident #1) reviewed for pharmacy services. ADON failed to make sure that drugs and biologicals are prepared and given by the same person by preparing a medication and giving it to CNA to administer to Resident #1, on 12/30/2024 around 10:30 AM per anonymous complaint dated 12/31/2024. This failure could place residents at risk for not receiving medications correctly.
Inspectors wroteBased on interviews, and record review, the facility failed to ensure each resident drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 5 residents (Resident #1) reviewed for pharmacy services. A. The facility failed to monitor, review, and reconcile Resident #1's medication administration record from April 2024- October 2024. This failure placed residents at risk for not receiving prescribed medications and drug diversion.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 2 residents (Residents #1 and #3) and 3 of 3 (LVN D, CNA G and CNA H) staff reviewed for infection control. LVN D failed to follow enhanced barrier precautions, change gloves, and wash her hands or use ABHR during Resident #1's and #3's wound care and Resident #3's transfer to bed. CNA G failed to follow enhanced barrier precautions before entering and exiting Resident #3's room. CNA H failed to follow enhanced barrier precautions before entering and exiting Resident #3's room and during the transfer of Resident #3 to bed. These failures could place residents at risk for spread of infection and cross contamination.
Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on the comprehensive assessment of residents for one of five residents (Residents #2) reviewed for wound care. The facility failed to follow physician's orders for wound care for Residents #2. The failure placed residents at risk of wound deterioration and infection.
Inspectors wroteBased on interview, observation, and record review the facility failed ensure residents with wounds receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure ulcers from developing or spreading for 1 of 2 Residents (Resident #1). The facility failed to follow physician's orders for Resident #1's pressure ulcer. This failure placed Residents at risks for infection and the development of new or worsening pressure injuries or wounds. Resident #1 Record review of Resident #1's clinical record reflected a face sheet, dated 09/12/24, which indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy for 1 of 1 residents (Resident #3 reviewed for privacy issues in that: 1. CNA A failed to provide full privacy for Resident #3 during peri care by not completely closing privacy curtains or providing a towel or sheet during peri care. 2. ADON failed to provide privacy by not providing a sheet or towel to cover the resident and not fully drawing Resident #3's curtain during peri care and wound care. This failure could cause residents to feel uncomfortable, disrespected, and possible exposure to anyone passing by.
Inspectors wroteBased 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 diseases and infections for 3 of 4 Residents observed for infection control for practices (Resident #2, #3, #4) in that: 1. CNA A failed to wash her hands before or during providing incontinent care for Resident #2. CNA A failed to wash her hands for the 15 seconds per facility policy. 2. CNA A failed to wash her hands before, during, and after providing incontinent care for Resident #3. 3. CNA A and CNA B failed to wash their hands before, during, and after providing incontinent care for Resident #4. These failures could place residents at risk for infection through cross contamination of pathogens.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Residents #1) reviewed for care plans. The facility failed to implement a care plan area for physician order for pressure ulcer treatment of coccyx (the small bone at the bottom of the spine), left thigh, coccyx, and left hip. The facility did not have a care plan area for Resident #1 removing his own dressing from his pressure ulcers. These failures could place residents at risk of not receiving the care required to meet their individualized needs.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure Resident 1's Physician Ordered dressings for the left thigh, coccyx, and left hip, based on the comprehensive assessment of a resident the resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for (Residents #1) resident reviewed for pressure ulcer care, in that: 1. Resident #1's pressure ulcer on his left thigh was observed being uncovered with no dressings. Resident #1's pressure ulcer on coccyx (a small bone at the base of the spinal column) was observed with having a dressing hanging off the backside above the pressure ulcer with the pressure ulcers being exposed. [...]
Inspectors wroteBased 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 dietary services. 1. The facility failed to ensure pots, pans and mixing bowls were stored in a manner to prevent contamination. 2. The facility failed to ensure foods were covered when being served out of the dining room. These failures could place residents at risk for food contamination and foodborne illness.
Inspectors wroteBased on interview and record review the facility failed to have physician orders for the resident's immediate care, at the time each resident was admitted for 1 of 3 residents (Resident #23) reviewed for admission Physician Orders. The facility failed to have Physician orders for dialysis treatments, graft dressing, changes and resident care before and after dialysis for Resident #23. This failure could place residents at risk of not receiving proper medical care related to dialysis services which could result in a decline in health.
Inspectors wroteBased on interview and record review the facility failed to ensure new residents were not admitted with mental disorders unless the State mental health authority had determined, based on an independent physical and mental evaluation performed by a person or entity other than the state mental health authority, prior to admission for 3 of 19 residents (Residents #11, #28 and #43) reviewed for PASARR screenings. The facility failed to ensure Residents #11, #28 and #43 had an accurate PASARR Level 1 assessment when they had a diagnosis of mental illness. This failure could place residents at risk for not receiving care and services to meet their needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 of 19 residents (Residents #9, #11 and #160) reviewed for care plans. This facility failed to develop a care plan for Residents #9, #11 and #160 to include bedrails. This failure could place residents at risk of not receiving the care required to meet their individualized needs.
Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Residents #23) reviewed for dialysis. The facility failed to ensure Resident #23 had physician's orders for dialysis treatments, graft dressing changes related to dialysis or resident care before and after dialysis. This failure could place residents at risk of not receiving proper medical care related to dialysis services which could result in a decline in health.
Inspectors wroteBased on observation, interview and record review the facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 3 of 19 residents (Resident #9, # 11 and #160) reviewed for bed rails. The facility failed to obtain consent prior to installing and utilizing bedrails for Residents #9, #11 and #160. This failure could place residents at risk for potential injuries.
Inspectors wroteBased on, interview, and record review the facility failed to ensure the resident environment remained free of accident and hazards for 1 of 5 residents (Residents #1) reviewed for accident hazards, in that:. CNA A failed to adhere verbal redirection from staff, verbal yelling from Resident #1 and failed to check resident position in her wheelchair causing her to fall out of her wheelchair sustaining 2 lacerations, one to the head and one to the neck and being transported to the local emergency department. These failures could place dependent residents at risk for falls, significant injuries and decreased quality of life.
Inspectors wroteBased on, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 2 of 5 (Resident #1 and Resident #2) reviewed for neglect. The ADM and DON failed to report Resident #1 fall that resulted in the resident sustaining 2 head laceration and being transported to a local emergency room. The ADM and DON failed to report Resident #2 fall that resulted in a Compression fracture of lumbar vertebra . [...]
Inspectors wroteBased on, interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 2 of 5 allegations reviewed for reporting alleged resident abuse (Resident #1 and Resident #2). The facility failed to ensure an allegation of neglect for Resident #1 was thoroughly investigated. The facility failed to ensure an allegation of neglect for Resident #2 was thoroughly investigated. these failures could place residents at risk of unidentified abuse due to allegations not being investigated as required.
3 fire safety citations on file: 2 on June 25, 2026, 1 on April 10, 2025.
| Date | Penalty | Amount or length |
|---|---|---|
| January 17, 2024 | Fine | $8,994 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Texas | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.13 | 3.39 | 3.86 |
| Registered nurses | 0.21 | 0.43 | 0.69 |
| All nursing staff on weekends | 2.75 | 2.98 | 3.42 |
| Nurse aides | 1.97 | ||
| Licensed practical nurses | 0.96 | ||
| Nursing staff turnover (share who left in a year) | 82.2% | 55.3% | 45.8% |
| Registered nurse turnover | 66.7% | 54.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.76 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.29 on weekdays and 2.75 on weekends, 16% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.17 in April to June 2025 to 3.13 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.13 | 0.21 | 3.29 | 2.75 | 0.0% | 0 of 90 | 59 |
| Oct to Dec 2025 | 2.87 | 0.23 | 2.99 | 2.59 | 0.0% | 0 of 92 | 61 |
| Jul to Sep 2025 | 2.79 | 0.36 | 2.94 | 2.40 | 0.0% | 0 of 92 | 54 |
| Apr to Jun 2025 | 3.17 | 0.31 | 3.34 | 2.74 | 0.1% | 0 of 91 | 50 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Texas, Jan to Mar 2026 | 3.33 | 0.40 | 3.50 | 2.93 | 2.2% | 0.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Texas, all employers | |||
| CNAs (nursing assistants) | $18.03 | $16.97 to $20.71 | 88,680 |
| LPNs and LVNs | $29.92 | $27.46 to $32.89 | 57,560 |
| Registered nurses | $46.14 | $38.06 to $50.53 | 271,380 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Texas | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 28.7 | 15.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.4 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.6 | 0.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 5.0 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 37.8 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 13.0 | 3.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 7.2 | 9.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 16.7 | 25.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 9.5 | 12.3 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.3 | 2.2 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.7 | 2.1 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Lakeside Rehabilitation and Care Center's Medicare short-stay residents. How to read these, and what Medicare pays for.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 51.5% · Texas: 116 better, 50 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 17 eligible stays.
11.1% this home
No different from the national rate
US median of homes 10.7% · Texas: 0 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 34 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 7.1% · Texas: 4 better, 11 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 23 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Texas57.3% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 11 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Texas0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 12 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Texas1.3% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 12 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Texas98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 1 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: STRATFORD HOSPITAL DISTRICT. CMS links this home to Skyblue Healthcare, a group of 12 nursing homes averaging 2.4 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Stratford Hospital District | 5% or greater direct ownership interest | Organization | 100% | 12/01/2017 |
| Chumley, Richard | Corporate director | Individual | 05/01/2007 | |
| Davis, Laura | Corporate director | Individual | 12/01/2014 | |
| Fedric, Leonda | Corporate director | Individual | 01/01/2013 | |
| Reinart, Janet | Corporate director | Individual | 05/01/2010 | |
| Wright, Cecil | Corporate director | Individual | 09/16/2014 | |
| Yelek, Cecily | Corporate director | Individual | 01/01/2013 | |
| Skyblue Healthcare Management LLC | Operational/managerial control | Organization | 02/01/2018 | |
| Stratford Hospital District | Operational/managerial control | Organization | 12/01/2017 | |
| Fleming, Dusty | Operational/managerial control | Individual | 02/17/2025 | |
| Ganz, David | Operational/managerial control | Individual | 02/01/2018 | |
| Skinner, Derek | Operational/managerial control | Individual | 12/01/2017 | |
| Stratford Hospital District | Adp of the SNF | Organization | 03/31/2025 | |
| Fleming, Dusty | Adp of the SNF | Individual | 02/17/2025 | |
| Ganz, David | Adp of the SNF | Individual | 02/01/2018 | |
| Skinner, Derek | Adp of the SNF | Individual | 12/01/2017 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Texas. NursingHomeClear cannot take or act on complaints.