Woodlands Rehabilitation And Healthcare Center

Location & what’s nearby

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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

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.

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.

54.1% 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 195 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 45.6% 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 68 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 0.45 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 28% 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.

Staffing

How full it usually is: this home is certified for 145 beds and averages 137.8 residents a day — about 95% occupied, or roughly 7 beds typically open. It runs essentially full — expect a waiting list. 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 3.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 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 3.13 hrs/resident/day on weekends vs 4.00 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.72 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as 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.

32 citations, most serious first. The 15 most serious are shown; the remaining 17 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-03-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure 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

  Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent Resident #1, a vulnerable resident, from leaving the facility premises unsupervised for one (1) of six (6) residents reviewed. Resident #1. On 3/22/25 at 8:17 AM, Resident #1, who has a Brief Interview for Mental Status (BIMS) score of 7, left the facility unsupervised. The facility's transportation aide let the resident out of the front door to sit on the porch. Licensed Practical Nurse (LPN) #1 encountered Resident #1 in the facility parking lot and attempted to redirect the resident back to the facility. She left the resident unsupervised to get help from additional staff. When staff returned, the resident had moved further off-site, and was across the street in a daycare parking lot, approximately one-fourth (1/4) of a mile from the facility. The resident was out of sight and unsupervised for approximately 13 minutes. The facility's failure to adequately supervise Resident #1, a vulnerable resident, put this resident and all other vulnerable…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2025-02-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  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, record review, and facility policy review, the facility failed to protect the residents' right to be free from physical abuse from a staff member for one (1) of five (5) sampled residents. Resident #1 Resident #1 was physically and emotionally abused on 12/25/24 when Certified Nursing Aide (CNA) #1 handled him roughly, sprayed cold water on his face, and turned out the lights in the shower room, while laughing. The facility's failure to protect resulted in Resident #1 reporting he felt sad, taken advantage of, and a little afraid. Additionally, the facility's failure to immediately remove CNA #1 from the facility placed this resident and other residents in a situation that was likely to result in ongoing serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The State Agency (SA) notified the Administrator of the IJ and SQC on 2/3/25 at 2:40 PM and provided an IJ Template. Based on 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2025-02-03 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to report an allegation of abuse within the required two (2) hour timeframe for one (1) of five (5) sampled residents. Resident #1 Licensed Practical Nurse (LPN) #1 witnessed physical and emotional abuse of Resident #1 on 12/25/24, however, the facility did not report it to the State Agency (SA) until 12/30/24, delaying the facility's ability to protect the resident from further harm. The facility's failure to ensure immediate reporting increased the risk of further harm which left Resident #1 and other residents in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The State Agency (SA) notified the Administrator of the IJ and SQC on 2/3/25 at 2:40 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 12/31/24, the SA determined the IJ and SQC 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Actual harm · G2024-06-06 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, resident and staff interview, and facility policy review the facility failed to notify the physician of a resident's severe pain rated initially at a ten (10) on a pain scale of (0-10) with 10 being the most severe for one (1) of four (4) sampled residents. Resident #2. Findings include: Record review of the facility policy titled Medication Policies, revised 10/1/19, revealed, .Procedure .12. When contacting the attending physician regarding a change in condition where it is likely the physician will order a medication, the nurse is to inform the physician of the availability of remote medications in the facility (i.e. the contents of the remote drug supply). This will facilitate timely drug administration . During a telephone interview on 6/6/24 at 12:20 PM, Resident #2 revealed that upon arrival/admission at the facility, she reported severe pain in her right hip. She reported that she did not receive any medication for pain until later in the evening. The resident was unable to recall the exact time but reported that it was hours after her arrival. She…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-06-06 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff and resident interview, record review and facility policy review, the facility failed to respond and administer pain medication timely for a resident's complaint of severe pain rated initially at a ten (10) on a pain scale of (0-10) with 10 being the most severe for one (1) of four (4) sampled residents. Resident #2. Findings Include: Record review of the facility policy titled, Pain Management Program Policy, revised 10/22, revealed, The facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management . Monitoring . 5. If a resident is experiencing pain during that shift, then pain medication and or alternative therapies should be administered as ordered . Additional Guidance . If pain has not been adequately controlled, it may be necessary to reconsider the current approaches and revise or supplement them as indicated . Record review of the facility policy titled Medication Policies, revised 10/1/19, revealed, Subsection:…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-07-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and facility policy review, the facility failed to implement physician ordered treatments for one (1) of eight (8) residents sampled residents. Resident #2.Findings include:A record review of the facility policy titled Medication Orders, revised 11/2014, revealed the purpose of the procedure is to establish uniform guidelines for receiving and recording all medication and treatment orders. The policy further revealed treatment orders are to specify the treatment, frequency, and duration of the treatment.On 7/1/26 at 12:52 PM, during a phone interview, Resident #2's Patient Advocate stated Resident #2 never received ice to her surgical site during her stay despite being instructed it was to be provided following surgery.On 7/1/26 at 1:35 PM, during an interview, the Director of Nursing (DON) stated medical records staff enter hospital discharge orders into the electronic medical record and the admitting nurse reviews the orders.On 7/1/26 at 2:30 PM, during an interview, Licensed Practical Nurse #1 stated she enters hospital discharge medication…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · Dcited before2026-07-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and facility policy review, the facility failed to provide appropriate perineal care by thoroughly cleansing the perineal area following an incontinent episode for one (1) of three (3) residents observed receiving incontinent care. Resident #6.Findings include:A record review of the facility policy titled Perineal Care, revised 3/3/26, revealed the purpose of the procedure is to provide cleanliness and comfort, prevent infection and skin irritation, and observe the resident's skin condition. The policy further revealed that for female residents staff are to separate the labia and cleanse from front to back.On 7/1/26 at 9:40 AM, Certified Nursing Assistant (CNA) #1 was observed providing incontinent care to Resident #6. The resident's brief contained feces. CNA #1 cleansed the perineal area multiple times but did not separate the labia while cleansing. After completing care and applying a clean brief, the State Agency staff requested the CNA reassess the resident's cleanliness. Upon removal of the clean brief, feces remained on 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · D2026-04-29 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  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, record review, and facility policy review the facility failed to ensure residents were treated with respect and dignity during the provision of care for two (2) of three (3) sampled residents. Resident #2 and Resident #3. Findings Included:Record review of the facility policy, Nursing Facility Resident Rights dated 3/06/26 revealed, The following rights are guaranteed to residents.To be treated with dignity, courtesy and respect.To privacy during personal care, visits, and phone calls .Record review of the facility document titled, Skills Checklist: Feeding a Resident (undated) revealed Procedure Step 11. Stated, Sits facing resident. Sits at resident's eye level. Sits on the stronger side if resident has one-sided weakness. Record review of the facility document titled, Peri care-Incontinent Care revised 1-2023 revealed the procedure indicated .Provide privacy (draw curtain from foot of bed to side up to wall, pull window curtain) .Resident #2On 4/28/26 at 12:55 PM, during an…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-29 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably 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, record review, and skills checklist review the facility failed to ensure a call light was maintained within reach for one (1) of three (3) residents. Resident #2.Findings Included:Record review of the facility policy document titled, Skills Checklist: Feeding a Resident (undated) revealed Procedure Step 21 Leaves call light within resident's reach . The facility was unable to provide a call light policy.On 4/28/26 at 2:15 PM, observation and interview revealed Resident #2 was awake and resting in bed with his lunch tray on the over the bed table in front of him. The resident's call light was lying on the floor under the head of his bed. He stated that he could use his call light but did not know where it was.On 4/29/26 at 12:00 PM, observation revealed that Resident #2 was resting in bed with his lunch tray on the over the bed table in front of him. The resident's call light was behind the head of his bed, hanging behind the mattress and out of the resident's sight and reach. He…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy review, and interviews the facility failed to provide treatment and care in accordance with professional standards of practice to prevent urinary tract infections for one (1) of three (3) sampled residents who required incontinent care. Resident #2Findings Included:Record review of the facility policy/procedure titled, Peri Care-Incontinent Care with revision Date 1-2023 (January 2023) revealed the procedure stated, FOR MALE RESIDENTS: For a male resident: a. Wet washcloth/cleaning wipes and apply soap or skin cleansing agent. b. Wash perineal area starting with urethra and working outward.c. Retract foreskin of the uncircumcised male. d. Wash and rinse urethral area using a circular motion. e. Continue to wash the perineal area including the penis, scrotum, and inner thighs. F. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth/cleaning wipes. G. Gently dry perineum following same sequence.On 4/28/26 at 12:55 PM, observation…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-08-15 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, record review, and facility policy review, the facility failed to maintain a medication error rate below five (5) percent (%), for two (2) of 31 medication opportunities observed, resulting in a 6.45 % medication error rate. Included was Resident #3, who was not instructed to rinse with water following administration of a steroid inhaler, and Resident #141, for whom the nurse prepared an incorrect dosage of Thiamine.Findings include:Record review of facility Medication Administration policy, reviewed and revised June 2025, revealed Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident right, right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #3On 8/13/2025 at 8:33 AM, during an observation of medication administration, Licensed Practical Nurse (LPN) # 5 administered Symbicort Inhalation Aerosol to…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-08-15 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, record review, and facility policy review, the facility failed to maintain an infection prevention and control program to help prevent the possible development and transmission of communicable diseases and infections for three (3) of 26 sampled residents, as evidenced by failing to conduct hand hygiene between glove changes (Resident #5 and Resident #115) and failing to adhere to Enhanced Barrier Precautions (EBP) during care (Resident #32).Findings Include: Review of the facility’s policy, “Infection Prevention and Control Program” with a revision date of 6/30/25 revealed “Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection…” Review of the facility’s “Non-Sterile Dressing Change Skills Checklist”, dated 6/27/25, revealed, “…Step 10 Remove gloves, place in plastic bag Step 11 Wash hands (or hand sanitizer) & put on gloves…” Review of the facility’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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-15 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview, record review, and facility policy review, the facility failed to ensure that a resident was informed of their right to formulate an advance directive (AD) and was provided assistance to do so for one (1) of (26) sampled residents (Resident #22).Findings Include:A review of the facility's policy, Resident Rights, undated, revealed, .Facility must protect and promote the rights of each resident, including each of the following rights . 5. Advance Directives .a. Facility will inform and provide written information to Resident concerning the right to accept or refuse medical or surgical treatment and, at the Resident's option, formulate an advance directive.A record review of Resident #22's clinical record revealed there was no documentation indicating whether the resident had been informed of ADs or was offered assistance by the facility in formulating one.On 8/12/25 at 8:00 AM, during an interview and concurrent observation of the electronic health record (EHR), Licensed Practical Nurse (LPN) #1 in Medical Records confirmed that Resident #22 had no…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-15 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, facility policy review, and interview, the facility failed to implement care plan interventions related to Enhanced Barrier Precautions for one (1) of 26 sampled residents (Resident #115). Findings included: Review of the facility’s policy “Care Plans Comprehensive Person-Centered”, with a review date of 6/2/25, revealed, “A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical psychological and functional needs is developed and implemented for each resident…” Record review of the “Care Plan Report” for Resident #115 revealed a “Focus” of “Resident requires Enhanced Barrier Precautions r/t (related to) Feeding tube” with “Interventions/Tasks” including “EBP…used during high-contact resident care activities as applicable such as…Changing briefs…” On 08/13/2025 at 1:58 PM, in an observation of Resident #115 receiving perineal revealed Certified Nursing Assistant (CNA) #2 did not wear a protective gown. On 08/13/2025 at 2:16 PM, in an interview with CNA #2 confirmed that she did…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure 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 ensure one (1) of five (5) sampled residents (Resident #140) received supervision and assistance during activities of daily living (ADL) bathing to prevent accidents or injury. The facility failed to ensure staff followed the resident's functional status, used appropriate transfer assistance, and sought help when the resident displayed signs of weakness during a shower transfer. Findings included:On 08/13/2025 at 11:44 AM, during an observation, Certified Nursing Assistant (CNA)# 3 was observed providing shower care to Resident #140. The resident was seated on a rolling shower chair and required transfer back to his wheelchair. CNA #3 instructed Resident #140 to stand twice to be dried and dressed. The resident was visibly weak and unsafe while standing both times. During the second attempt, the resident's arms were noted to shake while holding himself upright. No other staff were present during the bathing process, and CNA#3 did not…

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

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

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

Fines & penalties

$30,069 in federal fines across 4 penalties.

• $10,361 — penalty dated 2025-03-28
• $5,598 — penalty dated 2025-02-03
• $5,598 — penalty dated 2025-02-03
• $8,512 — penalty dated 2024-04-11

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

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 →

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

CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $993K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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 MS