Focused Care At Burnet Bay

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.

53.5% 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 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 45% 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 120 beds and averages 71.6 residents a day — about 60% occupied, or roughly 48 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.90 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.81 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 2.67 hrs/resident/day on weekends vs 3.00 on weekdays — 11% thinner on weekends. RN hours go from 0.43 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 30% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

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

25 citations, most serious first. The 15 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · J2024-04-23 · tag F0635 — isolated
  Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
  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 records reviewed, the facility failed to ensure at the time each resident was admitted , they had physician orders for immediate care for 1 (CR #1) of 5 residents reviewed for admission orders. -The facility failed to have physician orders for the use of a magnet device used when CR #1 was in respiratory distress on [DATE] and passed away at the facility. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of not receiving appropriate care and treatment services resulting in serious harm and/or risk of death. The findings included: Record review of CR #1's admission Record, dated [DATE], revealed a [AGE]…

  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
• Immediate jeopardy · J2024-04-23 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 (CR #1) of 5 residents reviewed for quality of care. -The facility failed to assess and provide treatment for CR #1's vagus nerve stimulator. On [DATE], facility staff used a magnet device when CR #1 was in respiratory distress and he passed away at the facility. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of not receiving appropriate care and treatment services resulting in serious harm and/or risk of death. 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
• Immediate jeopardy · J2024-04-23 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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 records reviewed, the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 (CR #1) of 5 residents reviewed for nursing services. -The facility failed to train nursing staff on how to use CR #1's magnet device. The magnet device was used on [DATE] when CR #1 was in respiratory distress and passed away at the facility. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of being cared for by insufficiently trained staff during a medical emergency resulting in serious injury…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-09-25 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  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 baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 (CR #1) of 5 residents reviewed for baseline care plans. -The facility failed to care plan and implement interventions to address CR #1's history of hallucinations, need for supervision, and behavioral interventions which resulted in CR #1 attempting suicide on 09/16/2023. An Immediate Jeopardy (IJ) was identified on 09/20/2023 at 5:15 p.m. While the IJ was removed on 09/23/2023 at 1:19 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure place residents at risk of not having their needs met, serious physical harm, injury, and/or death. The findings included: Record…

  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
• Immediate jeopardy · J2023-09-25 · 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 interviews and records reviewed, the facility failed to ensure resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (CR #1) of 5 residents reviewed for accident hazards and supervision. -The facility failed to provide adequate supervision for CR #1 to prevent harm from suicidal ideations and self-injurious behaviors that resulted in him cutting his arm and wrist with broken glass and being hospitalized . -The facility failed to care plan and put interventions in place for CR#1 when he admitted to the facility with history of hallucinations, need for behavioral monitoring for depression, and behavioral interventions to prevent suicidal attempts resulting in CR#1 cutting his arm and wrist. An Immediate Jeopardy (IJ) was identified on 09/20/2023 at 5:15 p.m. While the IJ was removed on 09/23/2023 at 1:19 p.m., the facility remained out of compliance at a scope of isolated and a severity…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-05-07 · tag F0641 — pattern
  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 observation, records review and interview, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 5 (Resident #4, # 10, #12, #51 and Resident #64) of 18 residents reviewed for accuracy of assessment.Resident #4, #10, #12's and #51's MDS did not reflect their lack of natural, broken\lose teeth in their oral cavity.Resident #64 was not assessed for her fall on 12/04/25.These failures could place residents at risk of receiving inadequate care and services due to inaccurate assessments. Findings included:Record review of Resident #4's face sheet, dated 05/06/26, reflected [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Essential hypertension (primary diagnoses), dementia (a group of symptoms affecting memory, thinking and social abilities), psychotic disturbance, overactive bladder, degenerative disease of envious system (a condition that damages, 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-07 · tag F0645 — isolated
  PASARR screening for Mental disorders or Intellectual Disabilities
  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 all Pre-admission Screening and Resident Review (PASRR) Level I for residents with mental illness were provided with an accurate PASRR Level I for 1 (Resident #10) and) of 4 Residents reviewed for PASRR screening.-Resident #10 did not have an accurate and updated PASRR Level 1 assessment reflecting a diagnosis of mental illness. This failure could place residents with mental illness at risk of not receiving a PASRR Evaluation for individualized care, or special services to meet their needs Findings included:Review of Resident #10's face sheet, dated 05/06/26, reflected [AGE] year-old female who was admitted to the facility on [DATE] re-admitted on [DATE]. Her diagnoses included chronic congestive heart failure, chromic kidney failure, schizophrenia, mood disturbance, presence of cardiac pacemaker, altered mental status, and Essential hypertension. High blood pressure)Record review of Resident #10's PASRR evaluation dated 11\19\23 revealed…

  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 · E2025-03-06 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 3 of 5 residents (Resident #39, #23, and CR #1) reviewed for abuse. 1. The facility failed to ensure Resident #39 was free from abuse when CR #1 hit her and made her cry on 3/7/24. 2. The facility failed to ensure Resident #23 was free from abuse when CR #1 screamed at her and made her cry on 1/16/24. These failures could place residents at risk for physical, mental, and psychosocial harm. The findings include: 1. Record review of Resident #39's face sheet, dated 3/14/24, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included dementia, need for assistance with personal care, anxiety, recurrent depressive disorders, hypertension (high blood pressure) and peripheral vascular disease (a common condition in which narrowed arteries reduce blood flow to the arms or legs).…

  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 · E2025-03-06 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  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 the medication error rate was not five percent or greater. The facility had a medication error rate of 28% based on 7 errors out of 25 opportunities which involved 3 of 8 residents (Residents #20, #44 and #16) and 2 of 5 staff (MA A and RN M) reviewed for medication administration. 1. The facility failed to ensure MA A did not crush and administer Potassium CL micro 10 mEQ ER (an extended-release medication, that should not be crushed, used to prevent or to treat low blood levels of potassium) and failed to ensure MA A administered the full dose of Clearlax 3350 (used to treat occasional constipation) to Resident #20 on 3/5/25. 2. The facility failed to ensure MA A did not administer Ciprofloxacin 3% eye drops (antibiotic eye drop) and Dexamethasone 0.1 % eye drops (a steroid medicine used to treat eye inflammation) to Resident #44 on 3/5/25, without a Physicians order. 3. The facility failed to ensure MA A provided sufficient…

  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 · D2025-03-06 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 6 residents (Resident #35) reviewed for PASRR (Preadmission Screening and Resident Review Services). The facility failed to ensure Resident #35 had a new level 1 PASRR screening completed with a new diagnosis of major depressive disorder and delusional disorders which were added on 4/2/24. This failure could place residents at risk of not receiving the needed PASRR services to meet their individual needs and could result in a decreased quality of life. The findings were: Record review of Resident #35's admission record, dated 3/5/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included metabolic encephalopathy, principal diagnosis (brain dysfunction caused by an underlying…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (Resident #14) reviewed for respiratory care. The facility failed to ensure Resident #14's oxygen was not administered at 5 liters per minute on 3/4/25 and 3/6/25 instead of 2-4 liters per minute as ordered by the physician. This failure could place residents at risk of not receiving medications and treatments as ordered by the physician. The findings include: 1. Record review of Resident #14's admission record, dated 3/6/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included cerebral infarction (stroke), dementia (a decline in cognitive functions such as memory, reasoning, and communication, significantly affecting daily life), congestive heart failure (a…

  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 · D2025-03-06 · 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

  Based on observation, interview and record review the facility failed ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 (medication room refrigerator) of 1 medication refrigerators reviewed for pharmacy storage. The facility failed to maintain the medication refrigerator in the medication room between 36-46 degrees Fahrenheit per facility policy. This failure could place residents at risk of not receiving the desired therapeutic effect from their medications. The findings include: Record review of the Med Room Refrigerator Log, dated March (no year), revealed on 3/1 the morning and evening temperature was 20 degrees Fahrenheit. From 3/2 - 3/4 the morning and evening temperature was 31 degrees Fahrenheit. From 3/5 - 3/6 the morning and evening temperature was 30 degrees Fahrenheit. The bottom of the log read, Maintain refrigerator temperature within the following range: 36 - 46 F. Temperatures were documented by MA A…

  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 · D2025-03-06 · tag F0803 — failed to meet residents' dietary needs — isolated
  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

  Based on observation, interview and record review the facility failed to ensure the menu was followed for one of one meal (lunch on 03/06/2025) reviewed for food and nutrition services. The facility failed to ensure the menu was followed for the lunch meal by leaving out the winter fruit cup, egg roll, or water for all diet types on 03/06/2025. This deficient practice could place residents at risk of dissatisfaction, poor intake, and/or weight loss. Findings include: Observation on 03/06/2025 at 11:52 AM, in the main dining area revealed trays were passed with a total of 18 residents in the dining room with 1 nurse. Upon observation, residents did not receive an egg roll, winter fruit cup, or water. Observation and record review on 03/06/2025 at 12:07 PM of the kitchen, revealed the food was already being put away and there was no food left on the steam tables. At that time, a test tray was requested, and the menu was reviewed. The menu displayed for 03/06/2025, reflected egg roll, mandarin chicken, steamed rice, seas broccoli florets, winter fruit cup, iced tea, and water. The test…

  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 · D2025-03-06 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 16 residents (Resident #16) reviewed for infection control. The facility failed to ensure RN M wore appropriate PPE when administering IV medication to Resident #16 on 3/5/25, who was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes). This failure could place residents at risk of infectious diseases due to improper infection control practices. Findings include: Record review of Resident #16's face sheet, dated 3/6/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #16 had diagnoses which included spontaneous bacterial peritonitis (an infection of the peritoneum, the thin…

  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 · F2023-12-13 · tag F0851 — widespread
  Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to electronically submit to CMS (Centers for Medicare & Medicaid Services) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 quarters (Fiscal year 2023 for the third quarter April 01, 2023 to June 30, 2023) reviewed for administration. -The facility failed to submit accurate registered nurse hours for the following dates: 04/01/2023, 04/02/2023, 04/08/2023, 05/13/2023, 05/14/2023, 05/20/2023, and 06/25/2023. This failure could place residents at risk for personal needs not being identified and met. Findings include: Record review of PBJ reporting for Quarter 3 (April 01, 2023 to June 30, 2023) indicated no RN hours for 04/01/2023, 04/02/2023, 04/08/2023, 05/13/2023, 05/14/2023, 05/20/2023, and 06/25/2023. Record Review of timecard editor for 04/01/2023, 04/02/2023, 04/08/2023, 05/13/2023, 05/14/2023, 05/20/2023, and 06/25/2023 revealed…

  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.

  Administration 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

$12,893 in federal fines across 1 penalty.

• $12,893 — penalty dated 2023-09-25

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 FOCUSED POST ACUTE CARE PARTNERS — 25 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 28 rows in the source record cover these 16 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.

4 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 80% 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 $267K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

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

What families pay in TX