Windsor Nursing and Rehabilitation Center of Alice

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.

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 136 beds and averages 73.5 residents a day — about 54% occupied, or roughly 62 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.20 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.21 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.96 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.86 hrs/resident/day on weekends vs 3.33 on weekdays — 14% thinner on weekends. RN hours go from 0.24 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

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.

25 citations, most serious first. The 13 most serious are shown; the remaining 12 are one tap away and print in full.

• Immediate jeopardy · J2025-07-03 · 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 observation, interview, and record review the facility failed to ensure each resident had the right to be free from abuse for seven residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident#15, Resident #20 and Resident #23) of 7 residents reviewed for abuse/neglect. 1. The facility failed to ensure Resident #2 was free from abuse, Resident #2 sustained a right hip fracture from being pushed by Resident #3 on 04/22/25. 2. The facility failed to ensure Residents #2 and #5 were free from abuse, Resident #4 hit Resident #3 in the back of the head causing a bump to her head and pushed Resident #5 that caused him to fall on top of another resident on 06/07/25 at 4:50 PM. 3. The facility failed to ensure Resident #15, Resident #20, and Resident #23 were free from abuse when Resident #15 struck Resident #20 on the back of his head with her phone causing an abrasion; and struck Resident #23 on his face with her phone on 03/24/25. The noncompliance was identified as PNC at an Immediate Jeopardy…

  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 · Jcited before2025-07-03 · 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, interviews, and record reviews the facility failed to ensure residents received adequate supervision to prevent accidents and/or hazards as possible for 1 of 12 residents (Resident #1) reviewed for supervision and accident hazards. The facility failed to ensure Resident #1 received adequate supervision in allowing Resident #1 to exit the facility without the knowledge of staff sometime between 6:30 PM and 7:00 PM on 05/16/25. An IJ was identified on 07/01/25. The IJ template was provided to the facility on [DATE] at 8:15 PM. While the IJ was removed on 07/03/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because new polices implemented to prevent future errors were still in process. This failure could place residents at risk for injuries and a decline in health. 1. Resident #1:Record review of Resident #1's face sheet dated 07/01/25 revealed a [AGE] year-old male with an admission date of 03/28/25. Pertinent…

  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
• Immediate jeopardy · Jcited before2025-01-03 · 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 observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of 4 residents reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 was unaccounted for approximately 29 minutes from 4:46 PM to 5:15 PM on 08/17/24 before a 3rd party notified CNA A that Resident #1 was in her wheelchair outside the facility. The noncompliance was identified as PNC. The PNC began on 08/17/24 and ended on 09/04/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents requiring supervision at risk for injury and accidents with potential for more than minimal harm. The findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old female with an original admission date of 12/01/22 and a current admission date of 08/06/23. Pertinent diagnoses included Vascular Dementia with…

  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
• Potential for harm · Ecited before2026-04-01 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety in the facility kitchen for 2 of 3 facility refrigerators, and 1 of 2 facility freezers reviewed for storage, preparation and sanitation. -The facility failed to ensure containers of tuna, corn, chocolate pudding, vanilla pudding, chilled fruit, and jello that were dated past the 72-hour used by date were thrown away.-The facility failed to ensure the safe storage of a bag of onions sitting next to the pail with cleaning chemical solution and a rag for cleaning purposes.-The facility failed to ensure 2 boxes of hashbrowns, and 1 box of bread dough were sealed and protected from cross contamination and exposure to splash, dust, or other contamination. These failures could place residents who receive meals and/or snacks from the kitchen at risk for food contamination and food borne illness. Findings included: Observations during the initial tour of the kitchen on 03/30/26 at 8:30 AM revealed a bag of onions sitting next to a pail of…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-01 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and revise the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments for 1 (Resident #5) of 5 residents reviewed for care plans. The facility failed to review and revise Resident #5's care plan with the current code status.This failure could place residents at risk of not receiving adequate or required care. The Findings included: Record review of Resident #5's face sheet dated [DATE] revealed Resident #5 was a [AGE] year-old male with an original admission date of [DATE], and a current admission date of [DATE]. Pertinent diagnoses included: Acute Respiratory Failure with Hypercapnia, (a life-threatening condition characterized by the inability to eliminate carbon dioxide). Chronic Obstructive Pulmonary Disease (COPD), (a progressive, irreversible lung disease that restricts airflow, causing severe breathing difficulties); Major Depressive Disorder (MDD), (a serious, common mental health…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-01 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 3 residents (Resident#33) reviewed for indwelling catheters. The facility failed to prevent Resident#33's urinary catheter bag from touching the floor. This failure could place residents at risk for cross contamination and urinary tract infections. Findings included: Record review of Resident#33's face sheet dated 03/30/2026 revealed a [AGE] year-old male admitted on [DATE]. Resident#33 admitted with diagnosis of obstructive and reflux uropathy (when flow of urine was blocked in the bladder, ureter. Record review of Resident #33's MDS dated [DATE], Section C-Cognitive patterns revealed Resident #33 had a BIMS score of 9 which indicated Resident #33 had moderately impaired cognition. Section H-Bladder and bowel revealed Resident #33 had an indwelling catheter.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided with such care, consistent with professional standards of practice, for 2 (Resident #56 and Resident #8) of 5 residents reviewed for respiratory care. 1.The facility failed to ensure Resident #56's oxygen was administered at the correct setting of 3 liters per minute on 03/30/2026 as ordered by the physician. 2.The facility failed to ensure Resident #8 had an emergency tracheostomy kit at the resident's bedside on 03/30/2026. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications, a decreased quality of care, and a delayed lifesaving intervention.Findings included: 1.Record review of Resident #56's face sheet dated 03/30/2026 revealed a [AGE] year-old female with an admission date of 12/30/2024 and an original date of 07/27/2023. Resident #56 had diagnoses of Respiratory Failure (condition where 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 date of correction
• Potential for harm · Dcited before2026-04-01 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were secured and stored in accordance with currently accepted professional principles and standards for 1 of 2 medication storage rooms (C Hall Medication Storage Room) reviewed for medication storage. The facility failed to ensure the C Hall Discontinued Medication cabinet was locked and secured. This failure could place the residents at risk of gaining access to unlocked medications that were not prescribed to them and place the facility at risk of drug diversion. Findings included: During an observation on [DATE] at 1:30 p.m., in the C hall medication strorage room,a cabinet that had discontinued medications was not locked and secured. In an interview on [DATE] at 1:35 p.m., LVN D stated he knew that the cabinet that stored the discontinued medications was supposed to be locked. He stated that he was not aware of the cabinet not being locked. He stated that he does not have a key for it but maybe the…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-01 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 3 (Resident #38, #14, and #66) of 8 residents reviewed for infection control practices.1. The facility failed to ensure MA A changed gloves after touching multiple surfaces during administration of eye drops on 03/31/2026 for Resident #38.2.The facility failed to ensure Resident #14 had EBP orders.3.The facility failed to ensure Resident #66 received safe and adequate wound care when the WCN failed to perform hand hygiene between glove changes, failed to allow hand sanitizer to dry on hands, failed to place a clean barrier between wound and bed, failed to use a clean cotton tip applicator when re-entering the medication cup, and failed to cleanse the wound adequately. These failures and deficient practices could…

  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 · D2026-03-03 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs for 1 (Resident #2) of 3 residents reviewed for medications. The facility failed to have an adequate indication for the use of the medication Risperidone (an antipsychotic with black box warning) for Resident #2 before administering the medication. This failure could put residents at risk of harm from adverse reactions or harmful side effects. Findings included: Record review of Resident #2's admission record dated 03/03/26, reflected a [AGE] year-old female with an admit date of 02/19/26 and an initial admission date of 04/11/22. Her relevant diagnoses included anxiety disorder (persistent, excessive fear or worry that interferes with daily life), major depressive disorder (a serious, common mood disorder characterized by persistent sadness, loss of interest in activities, and fatigue), dementia with behavioral disturbance (agitation, aggression, psychosis, depression, and apathy).…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-09 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 5 residents (Resident #1) reviewed for infection control practices. The facility failed to ensure LVN-A donned gloves and performed proper hand hygiene when dealing with secretions and body fluids. These failures could place residents at risk for cross contamination and infection. Findings included:Record review of Resident #1's face sheet, dated 10/01/25, revealed a [AGE] year-old-female with an admission date of 09/04/25. Diagnoses included Cerebral Infarction Unspecified (a stroke, when blood supply to a part of the brain is interrupted or reduced, preventing brain tissue from receiving oxygen and nutrients), Expressive Language Disorder (a communication challenge which affects a person's ability 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-07-03 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 3 Residents (Resident #4, Resident #15, and Resident #3) out of 4 investigated for abuse in the facility, in that: The facility failed to enforce the abuse policy correctly during investigations of abuse for Resident #'s 3, 4 and 15. Investigations were found to be inconclusive based on an incorrect interpretation of the definition of abuse and willful. The ADM and DON were not able to define abuse or willful correctly, making them incapable of determining whether abuse occurred at the facility or not. The ADM was the abuse prevention coordinator at the facility in charge of investigating abuse allegations. This failure could place residents at risk of abuse and neglect.The findings included:Record review of Resident #4's Face Sheet dated 07/01/25 revealed a [AGE] year-old female initially…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-02-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation, and sanitation. The facility failed to ensure kitchen equipment was in good condition. This failures could place residents at risk for complications from food contamination. The findings included: Observation of the kitchen during initial tour on 02/24/25 at 10:20 AM revealed a 3-door refrigerator and a 2-door refrigerator. The temperature in both refrigerator was below 41 degrees Fahrenheit. It was noted that on both refrigerator's when one door was closed the other door(s) opened. In an interview on 02/24/25 at 10:30 a.m., the DM stated the refrigerator doors in both refrigerators had not been closing properly since December 2024 (when he was hired). He said he had already reported it to the facility's Maintenance Director several times. He said he and his staff had too constantly be checking the doors to make sure they remained closed. The Dietary…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“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

$31,463 in federal fines across 3 penalties.

• $9,113 — penalty dated 2025-07-03
• $14,069 — penalty dated 2025-07-03
• $8,281 — penalty dated 2025-01-03

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

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 42 rows in the source record cover these 30 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

11 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 87% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX