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The Arbour At Westminster Manor

4200 Jackson Ave, Austin, TX 78731 · Non profit - Corporation · 90 certified beds · (512) 454-4711 Medicare only — no Medicaid

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Sep 20241 immediate-jeopardy citation$29,085 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2024
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • the CMS record shows $29,085 in federal fines (most recent 2024-09-25)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1912 W 35th St · (512) 451-5161 · Call to confirm hours
Pharmacy
1800 W 35th St · (512) 465-9292 · Call to confirm hours
Grocery
Ryan Lee0.8 mi
4404 Burnet Rd
Park
Typically dawn to dusk

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

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.2%15.8%15.4%better
Long-stay residents who lose too much weight0.6%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.7%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms2.0%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.3%3.3%3.3%typical
Long-stay residents whose ability to walk worsened4.0%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication9.8%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine96.7%98.0%95.3%typical
Long-stay residents with pressure ulcers2.3%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control5.7%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table8.2%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine80.2%88.0%79.4%typical
Short-stay residents rehospitalized after admission24.7%25.7%22.6%typical
Short-stay residents with an outpatient ER visit6.0%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days2.132.171.67worse
Long-stay outpatient ER visits per 1,000 resident days0.302.061.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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.

47.0% 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 148 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.0%U.S. median 51.5%
Got home and stayed home
11.9%U.S. median 10.7%
Went back to hospital
80.5%U.S. median 56.6%
Met the expected recovery
0.42U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.13hours / resident / day
Speech therapy

Met the expected recovery: 80.5% 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 128 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 0.42 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF47.0%CMS range 40.8–53.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.9%CMS range 8.5–15.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge80.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge84.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge73.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge99.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.4%CMS range 4.0–11.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.60
RN hours/ resident / day
0.94
LPN hours/ resident / day
3.43
Aide hours/ resident / day
4.96
Total nurse hours/ resident / day
0.52
RN hoursweekends
40.4%
Total nursing turnover
54.5%
RN turnover

How full it usually is: this home is certified for 90 beds and averages 81.0 residents a day — about 90% occupied, or roughly 9 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 4.96 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.43 is at or above 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 4.46 hrs/resident/day on weekends vs 5.17 on weekdays — 14% thinner on weekends. RN hours go from 0.63 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

2
deficiencies at the latest standard inspection (2025-12-03)
3
at the previous standard inspection (2024-09-25)

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.

ABCDEFGHIJKL

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.

  • Immediate jeopardy · J2024-09-25 · 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 resident had the right to be free from abuse for one resident (Resident #44) of six residents reviewed for freedom from abuse. The facility failed to protect Resident #44 from an aggressive family member with suspected history of abuse. On 08/03/2024 at about 6:30pm, during the dinner, the family member shouted at Resident #44 and forcefully fed her against her will by putting the spoon with food in her mouth, as witnessed by staff members. On 09/24/24 at 4:36 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/25/24, the facility remained out of compliance at a scope of isolated and a severity J level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed the residents at risk for mental and physical harm. Findings included: Review of Resident #44's face sheet dated 09/12/24 reflected,…

    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 · E2025-12-03 · 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, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to seal the food in the freezer. The facility failed to ensure that items were labeled and dated in the freezer. These failures could place residents at risk for consuming contaminated food and developing foodborne illnesses. An observation made on 12/01/2025 at 9:00 AM, of the walk-in freezer revealed food boxes stored on top of crates, unlabeled unidentified food items, and there was food opened in a bag that was not sealed, and the food was exposed to the air. An observation made on 12/01/2025 at 1:30 PM, revealed a variety of packaged food was still on the crate inside the walk-in freezer. An observation made on 12/02/2025 at 10:40 AM, revealed new unidentified food boxes inside the walk-in refrigerator on the floor and walk in freezer on the floor. During the observation, the opened unlabeled food items were still opened…

    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 before2025-12-03 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 assessments accurately reflected the resident's status for 1 of 6 residents (Resident #25) reviewed for accuracy of assessments. The facility failed to ensure Resident #25's MDS assessments date 10/01/2025 reflected his contractures on both his hands. This failure could place residents at risk of inadequate care due to an inaccurate MDS assessment. Findings include:Record review of Resident #25's face sheet, dated 12/02/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #25 had a diagnoses including dementia (memory, thinking, difficulty), anxiety (feeling of uneasiness or worry), hypertension (high blood pressure), gout (swollen arthritis), hyperlipidemia (high cholesterol), and depression (persistent feeling of sadness). Record review of Resident #25's quarterly MDS dated [DATE], revealed Resident #25 had a BIMS of 99 indicated unable to complete the interview. The MDS also revealed that Resident #25 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · 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 residents had the right to receive services in the facility with reasonable accommodation of the resident's needs and preferences for 1 of 8 residents (Resident #59) reviewed for accommodation of needs. The facility failed to ensure Resident #59's call light button was within her reach to call for nursing assistance. This failure placed residents at risk of having their needs gone unmet. Findings included: Record review or Resident #59's AR, dated 9/10/2024, reflected a [AGE] year-old female, born on [DATE], who admitted to the facility on [DATE]. She was diagnosed with Fracture of T-11-T12 Vertebra (which was a fracture in the lower spine,) Fracture of Sacrum (which was a fracture of the large triangle shaped bone at the bottom of the spine,) and Repeated Falls (which was a medical code, utilized in diagnosing, to describe numerous past falls and future risk of falls.) Record review of Resident #59's admission MDS, dated [DATE],…

    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 · D2024-09-25 · 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 residents 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 2 of 10 Residents (Resident #43 and Resident #44) reviewed for care plans. Resident #43 The facility failed to ensure: 1. Resident #43's legs were elevated while sitting or sleeping. 2. Resident #43 wore her compression stockings. 2. Resident #43's door remained open, except when receiving care. Resident #44 The facility failed to develop a comprehensive care plan that included interventions to ensure safety of Resident # 44 from the visitor's aggressive, physical, and verbal behaviors. This failure could place residents at risk of continued abuse, and not reaching their highest practicable physical, mental, and psychosocial well-being. Findings included: Resident…

    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 · E2023-07-21 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to 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 disease and infection for 1 of 2 wings (East wing) on the second floor of the facility reviewed for infection control, in that: Laundry staff C did not sanitize her hands between residents' room. This deficient practice could place residents at-risk for infection due to improper care practices. The findings include: Observation on 07/18/2023 at 1:12 p.m. revealed Laundry staff C, on the second Eastside wing was passing clean clothing to the residents' room. Laundry staff C was observed going to 3 different rooms, placing clothing in closets and drawers, without practicing hand hygiene. Interview with Laundry staff C, on 07/18/2023 at 1:18 p.m., Laundry staff C confirmed she did not sanitize her hands. Laundry staff C stated she had received infection control and hand hygiene training. Interview with the DON, on 07/20/2023 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-21 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 days calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition for 1 of 16 resident (Resident #61) reviewed for Comprehensive Assessments and timing. The facility failed to ensure an MDS Assessment for Resident #61 was completed within 14 days after admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings include: Record review of Resident #61's face sheet dated 07/21/2023, revealed an admission date of 06/21/2023, Record review of Resident #61's medical record revealed that as of 07/18/2023, no admission assessment MDS had been completed. Section A of the MDS assessment was still showing as incompleted. Interview with MDS Coordinator B on 07/21/23 at 11:40 a.m. revealed the time…

    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 before2023-07-21 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 complete an assessment which accurately reflected the resident's status for 1 of 18 (Resident #33) residents reviewed, in that: Resident #33's quarterly MDS assessment inaccurately documented 2 administrations of insulin which did not occur. This failure could result in inadequate care due to an inaccurate assessment of his medication administrations. The findings were: Record review of Resident #33's face sheet, dated 07/19/2023, revealed the male resident, aged [AGE] year, was admitted to the facility on [DATE] with diagnoses including: type 2 diabetes mellitus with hyperglycemia (a condition that occurs with elevated blood sugar levels), anxiety disorder unspecified (a condition in which feelings of worry and fear interfere with daily activities), and peripheral vascular disease unspecified (a condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #33's Quarterly MDS, dated [DATE], revealed a BIMS score…

    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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$29,085 in federal fines across 1 penalty.

  • $29,085 — penalty dated 2024-09-25

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 LIFE CARE SERVICES — 43 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 →

RatingThis homeChain avg
Overall 5 of 54.1+0.9 vs chain
Health inspection 4 of 53.7+0.3 vs chain
Staffing 4 of 54.4-0.4 vs chain
Quality measures 5 of 54.0+1.0 vs chain
The other 42 homes this chain runs (chain average 4.1★, per CMS)
1 of 5Burcham Hills Retirement CenterEast Lansing, MI 1 of 5Cottage Grove PlaceCedar Rapids, IA 2 of 5Casa De Las CampanasSan Diego, CA 2 of 5Linn Manor Care CenterMarion, IA 2 of 5Oakton Place Health And Rehabilitation At The ArliNaples, FL 2 of 5Pavilion At Brandon WildeEvans, GA 2 of 5Signature PointeDallas, TX 2 of 5The Stewart Health CenterCharlotte, NC 3 of 5Carillon INCLubbock, TX 3 of 5Friendship Village Of TempeTempe, AZ 3 of 5Westminster Village - West LafayetteWest Lafayette, IN 4 of 5Croasdaile VillageDurham, NC 4 of 5Dallas Retirement Village Health CenterDallas, OR 4 of 5Health Care Ctr At The Forum At Rancho San AntonioCupertino, CA 4 of 5Oaks Health Ctr At The Marshes Of Skidaway IslandSavannah, GA 4 of 5Parkwood VillageBedford, TX 4 of 5The Cedars of Chapel HillChapel Hill, NC 4 of 5Wesley Pines Retirement CommunityLumberton, NC 4 of 5Whitestone a Masonic and Eastern Star CommunityGreensboro, NC 5 of 5Acacia Health CenterPhoenix, AZ 5 of 5Avalon Health Care Center At StoneridgeMystic, CT 5 of 5Briarwood At Timber RidgeIssaquah, WA 5 of 5Chestnut Grn Hlth Ctr BlakehurTowson, MD 5 of 5Cypress Glen Retirement CommunityGreenville, NC 5 of 5Eastcastle Pl Bradford Ter Conv CtrMilwaukee, WI 5 of 5Essex Meadows Health CenterEssex, CT 5 of 5Friendship VillageKalamazoo, MI 5 of 5Green Hills Health Care CenterAmes, IA 5 of 5Greenwood Village SouthGreenwood, IN 5 of 5Hearthwood SNF Senior LivingBartlett, IL 5 of 5MarquetteIndianapolis, IN 5 of 5Premier Place At The GlenviewNaples, FL 5 of 5Radford GreenLincolnshire, IL 5 of 5Residences At Vantage PointColumbia, MD 5 of 5Rolling Green VillageGreenville, SC 5 of 5Somerfield At The HeritageBrentwood, TN 5 of 5Springs At Monarch Landing, TheNaperville, IL 5 of 5Terraces At The ClareChicago, IL 5 of 5The Birches At Trillium WoodsPlymouth, MN 5 of 5The Preston Health CenterHilton Head Island, SC

Showing 40 of 42; lowest-rated first.

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

Owner / managerTypeRoleShareSince
WESTMINSTER MANOROrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/06/1973
ALBRIGHT, ALEXANDRAIndividualCORPORATE DIRECTORsince 05/28/2020
ASHLEY, OLINIndividualCORPORATE DIRECTORsince 02/19/2015
BOYKIN, CUEIndividualCORPORATE DIRECTORsince 01/01/2026
CRIPE, JULIEIndividualCORPORATE DIRECTORsince 01/01/2026
DAY, MICHAELIndividualCORPORATE DIRECTORsince 01/01/2024
DINITTO, DIANAIndividualCORPORATE DIRECTORsince 07/01/2015
HILGERS, PAULIndividualCORPORATE DIRECTORsince 01/16/2014
LUEVANO, RICHARDIndividualCORPORATE DIRECTORsince 05/28/2020
MCEWAN, CHARLESIndividualCORPORATE DIRECTORsince 01/01/2026
MCGHEE, JOHNIndividualCORPORATE DIRECTORsince 01/01/2025
MILLER, ANNAIndividualCORPORATE DIRECTORsince 01/01/2022
REDDING, DAVIDIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2017
SCURLOCK, STEPHENIndividualCORPORATE DIRECTORsince 04/30/2020
SHERMAN, LYNNIndividualCORPORATE DIRECTORsince 01/01/2026
WILLIAMS, DIANEIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2019
WOODRICK, JAMESIndividualCORPORATE DIRECTORsince 01/01/2022
WOODWORTH, JAMESIndividualCORPORATE DIRECTORsince 01/16/2014
LIFE CARE SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/03/2025
BORST, CHARLESIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/25/2009
HALEY, CASSIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/10/2025
KROL, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/20/2023
LOYD, SARAHIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/24/2006

CMS files one row per role, so the 28 rows in the source record cover these 23 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.

$6.1M
Net patient revenuemost recent cost report
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 0%Medicare 9%Other / private 91%

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

$2,217per resident / day
operating cost
$67,398per month
≈ monthly operating cost
$273per day
avg. revenue, all payers

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

Paying with Medicaid

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Texas Medicaid page for homes that do.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676099. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-03, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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