Legend Oaks Healthcare And Rehabilitation - North

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.

47.6% 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 98 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 67.3% 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 52 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 0.89 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 124 beds and averages 109.9 residents a day — about 89% occupied, or roughly 14 beds typically open. It runs fairly full. 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 3.17 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 2.68 hrs/resident/day on weekends vs 3.37 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.72 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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.

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

• Immediate jeopardy · J2025-09-17 · 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 observations, interviews and record reviews the facility failed to ensure the facility did not use physical abuse for 1 of 2 Residents. The facility failed to ensure Resident #1 was free from abuse when CNA A and CNA B were changing the briefs of Resident # 1 on 08/17/2025. This failure could place residents at risk for serious psychosocial harm from abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.Findings included: Record review of Resident #1's admission Record, dated 09/03/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Unspecified Dementia, moderate (This is when symptoms become more severe, and the individual's ability to perform daily tasks declines significantly.), Hypertensive Heart (refers to heart conditions caused by high blood pressure.) and Chronic Kidney Disease (Gradual loss of kidney function.). Record review of Resident #1's quarterly MDS assessment dated…

  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 · J2025-09-17 · tag F0607 — failed to have anti-abuse policies — isolated
  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 observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for one of one resident (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to implement their policies and procedures to ensure Resident #1 was free from abuse when the facility failed to have effective interventions and services in place to address the resident's care, which resulted in Resident #1 sustaining Comminuted (bone that is broken in at least two places),(mildly displaced fracture of the base of the right first digital proximal phalanz (most basal bones of each digit.)with extension to the first digit joint time stamped 08.18.25 @ at 13:57 pm, reported signed by Doctor. An IJ was identified on 09/15/2025. The Administrator was notified and an IJ Template was provided on 09/15/2025 at 5:55 p.m. While the Immediate Jeopardy was…

  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 · Ecited before2026-04-23 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for three (Resident #3, Resident #31, and Resident #106) out of 10 residents reviewed for resident rights. The facility failed to knock on Resident #3's, Resident #31's and Resident # 106's doors prior to entry when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy is being invaded or the facility is not their home. Findings included: Review of Resident #3's Face Sheet dated 04/23/26 revealed he was a [AGE] year-old male who was readmitted to the facility on [DATE]. Resident #3's diagnoses included OTHER ACUTE OSTEOMYELITIS of LEFT ANKLE AND FOOT, (a rapid-onset bone infection), TYPE 2 DIABETES MELLITUS, (A condition results from insufficient production of insulin, causing high blood sugar.) and SCHIZOAFFECTIVE DISORDER, (includes bouts of hypomania or…

  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 · E2026-04-23 · tag F0803 — failed to meet residents' dietary needs — pattern
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 observation, interview, and record review, the facility failed to follow menus for 3 (Resident #2, Resident #23, and Resident #88) of 3 residents reviewed for a pureed diet. The facility failed to use a large enough scoop when serving residents on a pureed diet on 4/21/26, 4/22/26, and 4/23/26. This failure placed residents at risk for decreased intake and weight loss.Findings included: A record review of Resident #2's face sheet dated 4/23/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral infarction (stroke), atrial fibrillation (irregular heartbeat), dysphagia (difficulty swallowing), pneumonitis (inflammation of the lung) due to inhalation of food and vomit, muscle wasting and atrophy (muscle loss), cognitive communication deficit (difficulty communicating), gastrostomy status, (presence of feeding tube) and need for assistance with personal care. A record review of Resident #2's MDS assessment dated [DATE] reflected that she could not be assessed for BIMS because…

  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 · Ecited before2026-04-23 · tag F0919 — failed to provide a working call system — pattern
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  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 could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 4 of 17 residents (Resident #31, #41, # 42 and # 76) reviewed for the ability to call for staff assistance. The facility failed to provide a working communication system that was easily at reach, which would allow Resident #31, # 41, #42 and # 76 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living.Findings include: Review of the face sheet for Resident #41 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included PRIMARY OSTEOARTHRITIS (the protective cartilage that cushions the ends of the bones wears down over time.), CARPAL TUNNEL SYNDROME related…

  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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  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 were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 15 residents (Resident #79) reviewed for ADLs. The facility failed to ensure Resident #79 was provided with incontinent care after staff got her out of bed.This failure could place residents at risk of not receiving care services, diminished quality of life, and decreased self-esteem.Findings Included: Record review of Resident #79's face sheet, dated 04/22/2026, reflected a [AGE] year-old female, admitted [DATE] with diagnoses that included respiratory failure, heart failure, non-pressure chronic ulcer of skin of other sites with muscle involvement without evidence of necrosis (chronic skin loss often on the limbs extending to the muscle layer without tissue death), resistance to multiple antimicrobial drugs (when pathogens like bacteria, viruses, fungi or parasites no longer…

  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 · D2026-04-23 · tag F0687 — failed to care for feet properly — isolated
  Provide appropriate foot care.
  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 that residents received proper treatment and care to maintain mobility and good foot health for 1 (Resident #67) of 8 residents reviewed for foot care. The facility failed to obtain podiatry services for Resident #67. This failure placed residents at risk for toenail loss, pain, and infection.Findings included: A record review of Resident #67's face sheet dated 4/23/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of acute and chronic respiratory failure, morbid (severe) obesity, primary osteoarthritis (deterioration of cartilage), hypertensive heart and chronic kidney disease with heart failure, obstructive sleep apnea (sleep disorder), gout (form of arthritis), difficulty walking, unsteadiness on feet, cognitive communication deficit (difficulty communicating) and need for assistance with personal care. A record review of Resident #67's MDS assessment dated [DATE] reflected a BIMS score of 15, 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-23 · 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 provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 2 (Resident #51 and Resident #88) of 10 residents reviewed for medication administration. The facility failed to ensure Resident #51 took her medication while staff were present. Staff left Resident #51's medication on her bedside table for her to take. Resident #51 had not been assessed for self-administration.The facility failed to put Resident #88's inhaler back in the medication cart.The failure placed residents at risk of not taking their medication, or another resident getting the medication and taking the pills or the inhaler.Findings included: Record review of Resident #51's face sheet, dated 04/23/2026, reflected an [AGE] year-old female, admitted [DATE] with diagnoses that included dementia (memory, thinking, difficulty), muscle weakness, age-related cognitive decline,…

  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 · D2025-09-17 · 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 observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources were reported immediately, but no later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse to the Administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 6 residents ( Resident # 1 reviewed for abuse and neglect. The facility failed to report to HHSC when Resident #1 was found to have a significant bruise and swelling to right thumb of unknown origin on 08/17/25 at 3:03PM. This failure to report could place the residents at risk for abuse. Findings included:Record review of Resident #1's admission Record, dated 09/03/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included…

  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 · D2025-09-17 · 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 observation, interview, and record review, the facility failed to ensure accurate resident identification before transport for outside medical appointments for 1 (Resident #10) of 3 sampled residents. The facility failed to ensure that Resident #10 made it to his scheduled surgical appointment, and the facility sent the wrong resident in his place. This finding could place residents at risk for missing medical treatments. Record review Resident #10's medical diagnosis shows that Resident #10is diagnosed with hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (paralysis), heart failure, and major depressive disorder, recurrent moderate (depression). Resident #10 MDS showed that he had a BIMS of 10, which indicates moderate cognitive impairment. Resident #10.Interview on 9-17-2025 at 10:20 AM, an interview with Resident #10 said he did not make it to his cataract surgery, and he doesn't know what happened. Resident #10 told staff that he was scheduled to have an appointment. Resident #10 said that a CNA told him last night that 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 · D2025-09-17 · tag F0925 — failed to control pests — isolated
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  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 maintain an effective pest control program so that facility was free of pests and rodents for 1 of 7 bedrooms reviewed for physical environment. The facility failed to ensure that Resident #2's bedroom was free from ants. This finding could place residents at risk for bug bites, unsanitary environment and emotional distress. RR of Resident #2's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2 had diagnoses of Parkinson's Disease, Chronic Kidney Disease, and Muscle Weakness. RR of Resident #2's care plan dated 06/08/2023 revealed Resident #2 was at risk for impaired communication function/dementia r/t short term memory loss. RR of Resident #2's hospital record dated 08/14/2025 which triggered a visit for infected insect bite or sting. The record indicated a prescription for Cephalexin 500 MG CAP oral every 6 hours 10 days and Loratadine 10 MG tab oral daily. An observation was conducted 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-28 · tag F0573 — isolated
  Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
  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 reviews, the facility failed to ensure each resident had the right to access personal and medical records pertaining to himself or herself within 24 hours and allow the resident to obtain a copy of the records or any portions thereof upon request for 1 (Resident #1) of 6 residents reviewed for resident rights. The facility failed to provide a copy of Resident #1's medical records to Resident #1's RP after requesting the records on 02/21/25. This failure could place residents at risk of not having access to records when requested. Findings include: Review of Resident #1's Face Sheet, dated 04/28/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged from the facility on 01/13/25. Resident #1 was her own financial RP and care conference person and had someone designated as a financial RP and care conference person. Review of Resident #1's admission Record, dated 04/28/25, reflected she had diagnoses including unspecified dementia 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

“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

$42,726 in federal fines across 1 penalty.

• $42,726 — penalty dated 2025-09-17

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 THE ENSIGN GROUP — 342 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.

5 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.

This home reported $1.0M 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 TX