Winnie L Nursing & Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

Therapy staffing: this home’s payroll records show 0.38 therapist hours per resident per day in 2026Q1 — more than 65% 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 105 beds and averages 41.3 residents a day — about 39% occupied, or roughly 64 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 2.86 hrs/resident/day on weekends vs 3.44 on weekdays — 17% thinner on weekends. RN hours go from 0.26 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 88% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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.

34 citations, most serious first. The 15 most serious are shown; the remaining 19 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-08-14 · 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 provide adequate supervision for 1 of 5 residents reviewed for accidents and supervision. (Resident #1)The facility failed to ensure Resident #1 received adequate supervision to prevent elopement. On 08/07/2025 at an unknown time Resident #1 eloped from the facility by reading the door code that was placed by the door and let herself out the front door. Resident # 1 was found by CNA A standing on the front porch when she left work between 6:30PM and 7:00PM. The non-compliance was identified as past non-compliance. The immediate jeopardy began on 08/07/2025 at 6:50 PM and ended on 08/08/2025 2:20 PM .The facility had corrected the noncompliance prior to the start of the survey. The facility had implemented corrective actions and returned to compliance before the investigation began. This failure had the potential to affect other residents and could result in residents not receiving appropriate supervision, placing them at risk for…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2024-05-31 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately notify the resident's physician when there was an unwitnessed fall in the resident's physical status for one (Resident #1) of four residents reviewed for resident rights. The facility failed to ensure Resident #1's Physician was notified on 05/03/2024 when resident was found on the floor by CMA A. An Immediate Jeopardy (IJ) situation was identified on 05/30/2024 at 6:05 PM. While the IJ was removed on 05/31/2024 at 7:05 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy because all staff had not be trained on falls. This failure placed residents at risk of injury, uncontrolled pain, and a decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 05/30/2024 reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of fracture of unspecified part of neck of left femur, subsequent…

  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
• Immediate jeopardy · J2024-05-31 · tag F0659 — isolated
  Provide care by qualified persons according to each resident's written plan of care.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure services provided or arranged by the facility, as outlined by the comprehensive care plan were provided by qualified persons in accordance with each residents written plan of care for one (Resident #1) of four residents reviewed for qualified persons. The facility failed to ensure Resident #1 received assessment after an unwitnessed fall by a qualified staff member on 05/03/2024 when CMA A stated she conducted range of motion assessment, transferred the resident from the floor to the wheelchair and did not inform administrative staff. An Immediate Jeopardy (IJ) situation was identified on 05/30/2024 at 6:05 PM. While the IJ was removed on 05/31/2024 at 7:05 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy because all staff had not be trained on falls. These failures placed residents at risk for not receiving appropriate care and treatment by…

  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 · Jcited before2024-05-31 · 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 observation, interviews and record review , the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to ensure Resident #1, who was found on the floor by CMA A was properly assessed or monitored on 05/3/2024 until Resident #1 was transferred to the hospital on [DATE] at approximately 10:30 AM. An Immediate Jeopardy (IJ) situation was identified on 05/30/2024 at 6:05 PM. While the IJ was removed on 05/31/2024 at 7:05 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy because all staff had not be trained on falls. These failures could place residents at risk of not receiving necessary medical care, harm, and death. Findings included: Record review of Resident #1's face sheet dated 05/30/2024…

  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 · H2024-07-01 · 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 ensure residents were free of any significant medication errors for 1 of 4 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 received the medication Xarelto, an anticoagulant/blood thinner, which could have resulted in the resident developing or the worsening of a blood clot diagnosed soon after Resident #1 missed 24 doses of the medication from 05/15/24 to 06/08/24. This failure could place residents at risk of increased pain and health deterioration. Findings include: Record review of Resident #1's face sheet revealed she was an [AGE] year-old admitted to the facility on [DATE] with diagnoses including chronic embolism (obstruction of an artery usually by a blood clot or air bubble) and thrombosis (blood clot) of unspecified deep veins of right lower extremity, peripheral vascular disease (a circulatory disease-causing blood vessels to narrow) and chronic pain. Record review of Resident #1's…

  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 before2026-05-12 · 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 observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 medication carts (Medication Cart #1) reviewed for medication storage.The facility failed to ensure Medication Cart #1 were locked and medications were secured and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the counter medications. Findings included:Observation on 05/12/2026 at 4:40 p.m. revealed the locking mechanism protruding outward (indicated the medication cart was unlocked) on Medication cart #1 at the end of 400 hall. There was no nurses on the hall. In an interview on 05/12/2026 at 5:30 p.m. LVN B stated he forgot to lock medication cart when he exited 400 hall and entered another hall. He stated all medication carts were to be locked except when a nurse was obtaining medications from the cart. LVN B stated if 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 · D2026-05-12 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  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, interviews and record review, the facility failed to ensure residents had the right to be free from exploitation and misappropriation of property for one of four residents (Resident #1) reviewed for misappropriation of resident property.The facility failed to prevent a diversion (misappropriation) of Resident #1's Hydrocodone Oral Tablet 10-300 mg, 38 pills reported missing on 05/07/2026. Hydrocodone was used to treat pain.This failure could place residents at risk for decreased quality of life, unrelieved pain, and dignity.Findings included:Review of Resident #1's face sheet printed 05/12/2026 reflected a [AGE] year-old male admitted to the facility 02/02/2026. His diagnoses included unspecified subluxation of right patella subsequent encounter partial kneecap dislocation- considered serious, debilitating injury that requires medical evaluation-causes severe pain) and anxiety disorder (a group of treatable mental health conditions characterized by excessive, persistent, and uncontrollable…

  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 · Dcited before2026-05-12 · 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, interviews, and record reviews the facility failed to ensure the facility remained free of accidents and hazards a for one of two housekeepers carts (Housekeeping Cart #1) reviewed for hazards.The facility failed to ensure Housekeeping Cart #1, with chemicals inside the compartments, was locked when unsupervised. The housekeeping cart was located on 400 hall in front of room [ROOM NUMBER]. This failure could place residents at risk for injuries, illness, and hospitalization.Observation on 05/12/2026 at 9:03 am Housekeeping Cart #1 was located in front of 405 room. The compartment where chemicals were stored was not locked. The compartment had micro-kill bleach, disinfectant cleaner, Clorox, and two bottles filled with chemicals without a label on the bottles. Housekeeper G was not standing near the housekeeping cart. She exited room [ROOM NUMBER] at 9:00 a.m. and walked to the housekeeping cart and was standing beside surveyor. There were not any residents or staff in hallway when…

  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 · D2025-12-04 · 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 observation, interview and record reviews the facility failed to ensure that licensed nurses have the specific competencies, and skill sets necessary to care for residents' needs for 1 (LVN A) of 3 staff reviewed for nursing competency assessments after a fall for Resident # 1.The facility failed to ensure LVN A assessed Resident #1 for injuries after a fall. This failure could potentially affect the residents by placing them at risk for injuries. Findings include: Record review of Resident #1's face sheet, dated 09/19/2025, revealed Resident #1 was an [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Alzheimer's disease (a progressive brain disorder that destroys memory and thinking skills, leading to the inability to perform the simplest daily tasks), other specified bone density and structure, unspecified site (a bone disorder that changes the bone's density or structure but without a specific location or site being identified)…

  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
• Potential for harm · E2025-05-22 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
  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 the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Resident #24, Resident #11 and Resident #18) of 9 residents reviewed for accommodation of needs. 1. The facility failed to ensure that Residents #24's call light was within reach. 2. The facility failed to ensure that Resident #11's call light was within reach. 3. The facility failed to ensure that Resident #18's call light was within reach. These failures placed residents at risk of not being able to call for assistance and have their needs met. Findings included: 1. Record review of Resident #24's undated Face Sheet reflected she was a an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) late onset, difficulty in walking and cognitive…

  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 before2025-05-22 · 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

  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 for one of one medication storage rooms in the facility and one of three medication carts reviewed for medication safety. A. The facility failed to ensure expired supplies and/or medications were removed from the nurse's medication cart for the secure unit. B. The facility failed to ensure expired/discontinued supplies and/or medications were removed from the medication storage room. This failure could place residents at risk of not receiving the intended therapeutic benefits of their medications. Findings included: A. During an observation on 05/21/2025 at 10:25 AM of the medication cart for the secure unit with LVN B there were two insulin pens that were beyond the use dates of 28 days after opening for Resident #14. A Lantus Solostar Subcutaneous Solution Pen injector had an open date of 4/17/25, expired on 05/15/2025. An Insulin Lispro Subcutaneous…

  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 before2025-05-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 6 residents (Resident #6) reviewed for ADLs. The facility failed to ensure that assistance was provided to Resident #6 to remove all BM from hands and face before the lunch meal on 05/20/2025. This failure could place residents at risk of cross contamination and not being provided care and assistance when needed. Findings include: Review of Face Sheet for Resident #6 reflected an [AGE] year-old female admitted on [DATE]. Diagnoses included Alzheimer's Disease (dementia disorder related to protein formation in the brain), Acquired Absence of Left Upper Limb Above Elbow, and Need for Assistance with Personal care. Review of MDS for Resident #6 dated 02/12/2025 reflected a BIMS score of 2 (severe cognitive impairment). Section G0110 for Activities of Daily Living Assistance indicated…

  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 · Dcited before2025-05-22 · 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, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Residents #15) reviewed for accidents hazards and supervision: The facility failed to ensure Resident #15 had a fall mat in place and the bed was in the low position on 05/20/2025 while in bed. This failure could place the residents at risk for falls with the possibility of injury, including fractures. Findings include: Review of Face Sheet for Resident #15 reflected a [AGE] year-old man admitted on [DATE]. Diagnoses included: Dementia, Bipolar Disorder (a mental illness that causes extreme mood swings), Aphasia (difficulty using or comprehending language), and Deaf. Review of MDS for Resident #15 dated 05/02/2025 reflected a BIMS score of 1 (severe cognitive impairment). Section G0110 for Activities of Daily Living Assistance…

  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 · D2025-05-22 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs for one (Resident #32) of five residents reviewed for adequate monitoring of medication. The facility failed to discontinue an order for antipsychotic medication when ordered by the Medical Director with Medication Regimen Review with a Review date of 02/19/2025. This failure could place residents at risk of receiving discontinued and unnecessary antipsychotic medications. Findings included: Review of Face Sheet for Resident #32 reflected an [AGE] year-old male, admitted to the facility on [DATE]. Diagnoses included Dementia, Moderate, with other behavioral disturbance; Hypertension (high blood pressure), and Vitamin D Deficiency. Review of Care Plan for Resident #32 reflected a Focus Area stating The resident is risk for falls r/t Confusion, Deconditioning, Gait/balance problems, Psychoactive drug use, Unaware of safety needs, Wandering with a date initiated of 10/15/2024. There was 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 · Dcited before2025-05-12 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 2 residents (Resident #1) reviewed for change in condition . The facility failed to ensure Resident #1's RP was notified when she developed MASD (Moisture Associated Skin Damage) on her buttocks on 01/15/2025, and when it progressed to a non-pressure open area with drainage on 01/28/2025. This failure could place residents at risk of their responsible party/family members being unaware of their change in condition. Findings include: Record review of Resident #1's, undated, face sheet for Resident #1 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Cocaine dependence, in remission, Major Depression, and Paranoid Schizophrenia . She…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$51,479 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $10,549 — penalty dated 2025-08-14
• $40,930 — penalty dated 2024-05-31
• Medicare payment denial — starting 2024-07-02 for 20 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to CREATIVE SOLUTIONS IN HEALTHCARE — 149 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 14 rows in the source record cover these 11 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.

1 organizational owner 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.

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