West Oaks Nursing And Rehabilitation Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

46.6% 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 63 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 67.2% 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 61 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 0.90 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 9% 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 125 beds and averages 106.5 residents a day — about 85% occupied, or roughly 18 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 3.20 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 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 2.70 hrs/resident/day on weekends vs 3.40 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.49 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below the national median of 45%.

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

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

31 citations, most serious first. The 15 most serious are shown; the remaining 16 are one tap away and print in full.

• Immediate jeopardy · K2025-02-11 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  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 provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing and administering of all routine and emergency drugs and biologicals for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure that Resident #1's hospital discharge orders were followed to prevent rehospitalization due to hypoglycemia. 1. The facility failed to discontinue Resident #1's metformin and glyburide medications. 2. The facility failed to implement blood sugar monitoring for Resident #1. 3. The facility failed to start Resident #1 on the appetite stimulant (Mirtazapine) as ordered. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 02/10/2025 at 5:06 PM and an IJ template was given. While the IJ was removed on 02/11/2025 at 3:45 PM, the facility remained out of compliance at no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need…

  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
• Immediate jeopardy · Jcited before2024-03-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #2) of three residents reviewed for accidents and hazards, in that: The facility failed to ensure Resident #2 (who was a high-elopement risk) did not elope from the facility on 03/26/24 at 12:50 PM when the Receptionist used her remote-control door opener to unlock the front door. He was located over 24 hours later at a bus stop approximately 12 miles from the facility. The noncompliance was identified as PNC. The IJ began on 03/26/24 and ended on 03/27/24. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for unsafe elopements, falls, injuries, dehydration, and hospitalization. Findings included: Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [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.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2023-09-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure the resident(s) environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents, for 1 of 4 residents (Resident #72) reviewed for accident hazards and supervision, in that; 1.Resident #72 had 2 unauthorized, unchaperoned elopement events on 10/03/2022 and 01/03/2023, without the facility providing adequate safety interventions to prevent further elopement risks. An IJ was identified on 09/01/2023. The IJ template was provided to the facility on [DATE] at 05:30 PM. While the IJ was removed on 09/03/2023, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on elopement risk residents. The findings included: A record review of Resident #72's admission record, dated 08/31/2023,…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · H2024-04-10 · tag F0697 — failed to manage pain — pattern
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (Resident #3 reviewed for pain management. The facility failed to ensure Resident #3 received his 08:00 AM scheduled Norco on time for 7 of 10 days between 04/01/24 and 04/10/24. This failure placed residents at risk of increased pain and decreased quality of life. Findings included: Review of the undated face sheet for Resident #3 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included multiple sclerosis , chronic pain syndrome, muscle weakness, stage 4 pressure ulcer of left buttock, major depressive disorder, and high blood pressure. Review of the quarterly MDS assessment for Resident #3, dated 03/05/24, reflected a BIMS score of 15, indicating intact cognition. It…

  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
• Actual harm · Hcited before2024-04-10 · 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 record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #3 reviewed for medication administration. The facility failed to ensure Resident #3 received his 08:00 AM medications (Norco, Baclofen, Cozaar, and Cipro) on time for 7 of 10 days between 04/01/24 and 04/10/24. This failure placed residents at risk of not receiving the therapeutic benefit of their medications. Findings included : Review of the undated face sheet for Resident #3 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included multiple sclerosis, chronic pain syndrome, muscle weakness, stage 4 pressure ulcer of left buttock, major depressive disorder, and high blood pressure. Review of the quarterly MDS assessment for Resident #3, dated 03/05/24, reflected a BIMS score of 15,…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-02-25 · 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 treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #27, Resident #50, and Resident #109) reviewed for resident rights.The facility failed to ensure CNA D knocked on Resident #27's door before entering the resident's room.The facility failed to ensure CNA E knocked on Resident #109's door before entering the resident's room.The facility failed to ensure Resident #50's catheter bag had a privacy cover on.These failures could place residents at risk of feeling like their privacy was invaded or cause psychosocial harm and emotional distress.Findings include:1. Record review of Resident #27's face sheet, dated 02/24/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #27 had diagnoses which included reduced mobility, unsteadiness on feet, dementia…

  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 · E2026-02-25 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record reviews the facility failed to ensure residents had a right to organize and participate in resident groups in the facility for 10 of 10 confidential residents reviewed for resident council.The facility failed to provide the Resident Council with a private meeting area to conduct their monthly meetings. This failure could place residents at risk of not being able to exercise their rights to meet as a group in private. Findings include:During a confidential group interview/observation at an undisclosed date and time the group of ten residents stated they wanted to have a meeting where there were no interruptions. The meeting was in held in the activity room. The residents stated staff walked in while they were conducting their monthly council meeting. The residents' said they had to constantly stop their meeting or vote because people would interrupt. During this confidential group interview the meeting was interrupted by residents and staff six times within the hour-long meeting. The residents stated that it upset them, and they felt like…

  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 before2026-02-25 · 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, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 3 of 6 staff ( the DM, CK A and CK B) reviewed for food and nutrition services. The facility failed to ensure the DM, CK A and CK B wore appropriate hairnets so the hair was not exposed. This failure could place residents at risk of having hair in their food as well as ingesting contaminated food leading to illness.Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 3 of 6 staff ( the DM, CK A and CK B) reviewed for food and nutrition services. The facility failed to ensure the DM, CK A and CK B wore appropriate hairnets so the hair was not exposed. This failure could place residents at risk of having hair in their food as well as ingesting contaminated food leading to illness. Findings include: Observations on 02/23/26 at 09:00 AM revealed CK A's hairnet was not…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-02-25 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident #50, #11, and #99) reviewed for infection control. The facility failed to ensure Resident #50 and Resident #11's catheter drainage bags were positioned correctly and not touching the floor on 02/23/2026 and 02/24/2026.The facility failed to ensure MA performed hand hygiene before preparing medications for Resident #99.The facility failed to ensure the Blood pressure monitor was sanitized after it was picked up from the floor and placed on the medication cart for Resident #99. These failures could place residents at risk for cross contamination and the spread of infection.Findings include: 1. Record review of Resident #50's face sheet, dated 02/24/2026, reflected a [AGE] year-old female…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-25 · 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 2 of 5 residents (Resident #88 and Resident #91) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #91's annual MDS, dated [DATE], accurately reflected his smoking status. 2. The facility failed to ensure Resident #88's admission MDS, dated [DATE], accurately reflected her smoking status. These failures could place residents at risk of inadequate supervision due to an inaccurate assessment of smoking status. Findings include: 1. Record review of Resident #91's face sheet, dated 02/25/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #91 had diagnoses which included traumatic brain injury with loss of consciousness, muscle weakness, cognitive communication deficit, need for assistance with personal care, and lack of coordination. Record review of Resident #91's annual MDS, dated [DATE], reflected Resident #91 had a BIMS…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-25 · 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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents 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 #88) reviewed for care plans. The facility failed to ensure a comprehensive care plan was developed for Resident #88 to include her smoking status when the care plan was completed on 12/03/2025 and revised on 01/30/2026. This deficient practice could place residents at risk of not being provided with the necessary care or services and the implementation of personalized plan of care developed to address their specific needs.The findings include: Record review of Resident #88's face sheet, dated 12/17/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #88 had…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-25 · 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

  Based on observation and interview the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 of 1 medication rooms reviewed for pharmacy services.The facility failed to ensure expired and/or discontinued medications removed from use for one medication storage room.This failure could place residents at risk of not receiving the intended therapeutic benefits of medication.Findings include:During observation of medication storage room on 02/23/2026 at 3:03 p.m. revealed one bag of the Lactated Ringer's Injection USP (500mL) solution with an expiration date of 11/2025 stored inside of the box along with 5 unexpired bags of solutions. The DON present at the time of the observation, removed the expired packages from the room. The DON stated medications would be disposed of per facility policy.During an interview on 02/25/2026 at 3:18 p.m., the DON stated her expectation was all nurses were to place expired medications in medication destruction bins. The DON…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of eight residents reviewed for accidents and hazards. The facility failed to ensure Resident #1's wheelchair brakes were functional. This failure could place residents at risk for injury and decreased quality of life. The findings included: Review of Resident #1's face sheet dated 12/10/25 reflected a [AGE] year old male admitted to the facility on [DATE] with a diagnosis that included need for assistance with personal care, hemiplegia (one sided paralysis or weakness of the face, arm, or leg) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke) affecting the left non-dominant side, unspecified lack of coordination, unsteadiness on feet, cervical disc disorder with myelopathy (spinal cord compression)-…

  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 · E2024-11-26 · tag F0583 — failed to protect personal privacy — pattern
  Keep residents' personal and medical records private and confidential.
  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 resident rights for personal privacy for 4 of 15 residents (Resident #23, Resident #52, Resident #78 and Resident #93) residents reviewed for personal privacy. The facility failed to knock on Resident #23, Resident #52, Resident #78 and Resident #93's room 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 #23 Face Sheet dated 11/26/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #23's diagnoses included dementia (memory, thinking, difficulty), morbid obesity, insomnia (difficulty sleeping), hypertension (high blood pressure), major depressive disorder, cognitive communication deficit (problems with communication), muscle wasting, heart failure, muscle weakness, gout (swollen arthritis), and need for assistance 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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-11-26 · tag F0761 — failed to label and store drugs safely — pattern
  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

  Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to assure the accurate acquiring, receiving, dispensing, and administrating of all drugs and biologicals in accordance with currently accepted practices for 1 of 4 (Cart #1,) medication carts reviewed for pharmacy services in that: Medication Cart #1 for the 100 hall was left unattended with the keys in the lock and was not locked. This deficient practice could affect residents and result in a drug diversion causing an allergic reaction or a resident taking medication not prescribed for them due to medications not being properly secured. The findings were: Observation on 11/24/2024 at 10:37 am revealed that LVN D walked away from Cart #1 on the 100 hall and left the keys in the lock and the cart unlocked. Observation on 11/24/2024 at 11:04 a.m. of Medication Cart #1 for the 100 revealed it was not locked and had the keys hanging out the lock when LVN D went into a resident's room to administer medication. Observation on 11/24/2024 at 11:06 a.m. revealed LVN D walked away from…

  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

“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

$39,527 in federal fines across 2 penalties.

• $26,683 — penalty dated 2025-02-11
• $12,844 — penalty dated 2024-03-28

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 12 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $769K 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