Alvarado Meadows Nursing & Rehabilitation

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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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 115 beds and averages 58.4 residents a day — about 51% occupied, or roughly 57 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 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.24 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 2.99 hrs/resident/day on weekends vs 3.51 on weekdays — 15% thinner on weekends. RN hours go from 0.33 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 96% is well above the national median of 45%. 1 administrator has left in the past year.

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.

20 citations, most serious first. The 13 most serious are shown; the remaining 7 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-06-10 · 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 the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 out of 6 residents (Resident #1) reviewed for abuse/neglect. The facility failed to protect Resident #1 from physical abuse when LVN A forcefully dragged him to his bed on 05/26/2025 after an unwitnessed fall. An Immediate Jeopardy (IJ) existed from 05/26/2025 - 06/02/2025. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. This deficient practice could place residents at risk of abuse, injury, and psychosocial harm. Findings included: Record review of Resident #1's admission record, dated 06/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease (brain disorder that causes memory loss), chronic kidney…

  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 before2024-05-22 · 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 the residents had the right to be free from abuse for one (Resident #1) of five (5) residents reviewed for abuse, in that: The facility failed to prevent Resident # 1 from becoming sexually assaulted by Resident #2, who had a history of sexually inappropriate behaviors, when Resident #2 blocked Resident #1 in the shower room on 5/17/2024 and touched her breast, kissed her and masturbated in front of her. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/20/2024. The IJ template was provided to the facility on 5/20/2024 at 5:17 pm. While the IJ was removed on 05/22/2024 at 4:00 pm, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of sexual abuse with potential for…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-08-26 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the need of 1 (Resident # 1) of 5 residents reviewed for pharmacy services. The facility failed to follow the physician orders when administering Resident # 1's medications causing the resident to aspirate, have labored breathing and being sent to the hospital and being admitted due to aspiration. An (IJ) Immediate Jeopardy was identified on 8/24/2023 at 7:26pm. While the (IJ) Immediate Jeopardy was removed on 8/26/2023 at 5:00pm, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed all residents at risk for inadequate therapeutic outcomes, and a decline in health. Findings included: Record review of Resident #1 face sheet dated 8/24/2023,…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-07-02 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical and psychosocial status for one (Resident #1) of six residents reviewed for changes in condition.1. The facility failed to notify Resident #1's RP of Resident #1's antibiotic order for a skin infection on 05/31/26.2. The facility failed to notify Resident #1's RP of treatment for head lice 06/08/26.These failures could put residents at risk of not having their care needs and health changes communicated and addressed with their responsible party.Findings included:Record review of Resident #1's admission MDS dated [DATE] reflected she was admitted on [DATE] with diagnoses of Urinary tract infection, Vitamin B deficiency, weight loss, and visual hallucinations. Resident #1 had a Bims score of 3, indicating she had severe cognitive impairment. She required to set up clean up assistance with eating and supervision with dressing and…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-05-06 · tag F0550 — failed to protect resident dignity and rights — pattern
  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

  Based on observations and interviews, the facility failed to ensure residents were treated with dignity and respect during meal service for 3 of 11 residents observed in the G Hall (Male Memory Care Unit) dining area.Resident 11, Resident 42, and Resident 51 were observed being served lunch on transport trays typically used for meal delivery rather than being provided with a standard dining setting appropriate for residents.This failure had the potential to compromise residents' dignity and created a non-traditional dining experience that did not promote a homelike environment.Observations conducted on 05/04/2026, at 12:41 PM, revealed residents eating lunch in the common dining area of the Male Secured Unit. Residents were observed being served meals on transport trays. A male staff member assisted with meal setup, including providing utensils such as forks, knives, and spoons when needed; however, the meals remained on the transport trays during dining service.Observations conducted on 05/05/2026, revealed residents in the Male Secured Unit continued to be served lunch on…

  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 · Ecited before2026-05-06 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and records review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administ ering of all drugs and biologicals) to meet the needs of each resident. for one of one medication room (Medication room [ROOM NUMBER]), and for one of five medication carts (Medication Cart #1) inspected on 5/5/2026. The facility failed to dispose of: one box of expired Loperamide Hydrochloride, 2mg tablet, (an anti-diarrheal medication), with expiration date July 2025 in medication cart #1 (G hall Nurse cart). 28 syringes of expired AB 1MG-25/GM T/D Gel (topical anti-anxiety medication), with use by date of 12/1/2025 in medication room [ROOM NUMBER]. 3 syringes of expired Morphine Sulfate solution 100/5ML (oral narcotic pain medication), with use by date of 6/4/2026 in medication room [ROOM NUMBER]. One bottle of expired Hydromoprhone4 MG/ML syrup (oral narcotic pain medication) with best used by date 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-05-06 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, 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.The facility failed to ensure food items in the kitchen were properly labeled and dated.These failures had the potential to place residents consuming food prepared by the kitchen at risk for foodborne illness.During an observation conducted on 05/04/2026, at 9:32 AM Refrigerator #1: contained one large container of [NAME] Deluxe Mayonnaise and one bottle of Louisiana Hot Sauce that had been opened but was not labeled or datedDuring an observation conducted on 05/05/2026, at 12:07 PM, Freezer #1, contained two packages of prepared bread and two bags of single-serve ice cream that had no labels or use-by dates.During an interview on 05/06/2026, at approximately 11:37 AM, the DM stated when new items were received in the kitchen, staff checked for damage and labeled and dated items appropriately. The DM…

  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 · D2026-05-06 · tag F0637 — isolated
  Assess the resident when there is a significant change in condition
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the completion of a significant change assessment for 1 of 5 residents reviewed for Significant Change Assessments. (Resident #39).The facility did not complete a significant change assessment for Resident #39 within 14 days of being admitted to hospice services. This failure could place residents at risk of not receiving adequate services and reimbursement to meet their needs.The findings included:Record review of Resident #39 annual MDS dated [DATE] reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (a lung disorder making it difficult to breathe), mild intermittent asthma (narrowing of the airway), anxiety, and vascular dementia (a decline in memory function). Resident #39 had impaired short term and long-term memory and was receiving hospice care. Record review of Resident #39's Physician's Order Summary report reflected an order for Resident #39 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-10 · 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, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #3's call light was within reach on 06/05/2025. This failure could place residents at risk of their needs not being met. Findings include: Record review of Resident #3's admission record, dated 06/10/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: Alzheimer's disease with late onset (brain disorder that causes memory loss), bipolar disorder (mental health condition that cause extreme shifts in mood), essential primary hypertension (high blood pressure), and cognitive communication deficit (difficulty with thinking and using…

  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 · D2025-06-10 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort, which included incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for 2 of 2 residents (Resident #4 and Resident #5) reviewed. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting for Resident #4 and Resident #5. This failure could place residents at risk of not receiving necessary care or specialized services which could diminish the residents' quality of life and highest level of functioning. Findings include: Record review of Resident #4's admission record, dated 06/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which…

  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 before2025-06-10 · 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 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, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #2) reviewed for comprehensive care plans. Resident #2's comprehensive care plan did not reflect Resident #2 sustained a fracture to her upper right arm on 05/25/25. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings include: Record review of Resident #2's admission record, dated 06/10/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: unspecified dementia (the decline in thinking, remembering, and reasoning skills), cognitive communication deficit (difficulty 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-10 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview , and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care, in that: The facility failed to conduct weekly skin assessments for Resident #1 for the weeks of 05/11/25 through 05/17/25 and 05/18/25 through 05/24/25. These failures placed residents at risk of physical harm, pain, and a decreased quality of life. Findings included: Record review of Resident #1's admission record, dated 06/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease (brain disorder that causes memory loss), chronic kidney disease stage 3 (when your kidneys are damage and can't filter blood properly), muscle wasting and atrophy (decrease in size and wasting of muscle tissues), and lack of coordination (having…

  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 before2025-03-06 · tag F0656 — failed to write and follow a full care plan — pattern
  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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for four residents of 12 residents (Residents # 28, #29, #33, and #47) reviewed for care plans. The facility failed to ensure Residents # 28, #29, #33, and #47 care plans were complete and accurate. These failures could place the residents at risk of not receiving appropriate care. Findings included: 1. Record review of Resident #28's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, morbid obesity, and muscle wasting. Record review of Resident #28's quarterly MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Her Functional Abilities assessment indicated she was totally dependent on staff for toileting and needed maximum assistance with bathing and personal hygiene. Record review 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.

  Resident Assessment and Care Planning 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

$85,479 in federal fines across 5 penalties. 1 Medicare payment denial on record.

• $10,546 — penalty dated 2025-06-10
• $4,329 — penalty dated 2025-02-09
• $7,141 — penalty dated 2024-05-22
• $44,925 — penalty dated 2024-03-15
• $18,538 — penalty dated 2023-08-26
• Medicare payment denial — starting 2024-04-12 for 5 days

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 CREATIVE SOLUTIONS IN HEALTHCARE — 149 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 18 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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 86% 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX