Five Points Nursing & Rehabilitation of College St

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.

Met the expected recovery: 51.8% 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 56 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 0.38 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 130 beds and averages 95.7 residents a day — about 74% occupied, or roughly 34 beds typically open. It usually has some room. 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 2.69 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 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 2.32 hrs/resident/day on weekends vs 2.84 on weekdays — 18% thinner on weekends. RN hours go from 0.39 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

Inspection trend

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

Inspection deficiencies

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

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

29 citations, most serious first. The 16 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-12-22 · 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 review the facility failed to ensure that 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 1 (Resident #2) of 3 residents. The facility failed, on 12/08/25, to ensure two staff members assisted Resident #2 off the toilet and onto her wheelchair. Resident #2 fell and hit her knee on the toilet paper dispenser when CNA E transferred her off the toilet alone. Resident complained of pain. On 12/10/25 an x-ray revealed Resident #2 had a broken femur, was sent to the hospital and had surgery. An Immediate Jeopardy (IJ) was identified on 12/21/2025. The IJ template was provided to the facility on [DATE] at 2:07 pm. While the IJ was removed on 12/22/25 at 7:54 pm, the facility remained out of compliance at a scope of isolated and severity level of no actual harm. Findings included: Record review of Resident #2's face sheet, dated 12/21/25, revealed 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
• Immediate jeopardy · J2025-08-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews 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 1 out of 8 residents (Resident #1) reviewed for abuse/neglect. The facility failed to ensure Resident #1 was not neglected by not checking on Resident #1 from 2:40pm - 4:40pm on 08/26/2025. Resident #1 was found outside with a temperature of 104 degrees [F] and sent to the hospital due to being unresponsive and tachycardic (your heart is beating too fast, over 100 times a minute at rest). The temperature on 08/26/25 was a high of 97 degrees [F]. An IJ was identified on 08/28/2025 at 4:15 PM. While the IJ was removed on 08/29/2025 at 10:27 AM, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems This deficient…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-08-29 · 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 review the facility failed to ensure each resident received adequate supervision for 1 of 8 resident (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 had adequate supervision or was checked on for over two hours as he was found outside on 08/26/25 with a temperature of 104 degrees [F] and sent to the hospital due to being unresponsive and tachycardic (your heart is beating too fast, over 100 times a minute at rest). The temperature on 08/26/25 was a high of 97 degrees [F]. An IJ was identified on 08/28/2025 at 4:15 PM. While the IJ was removed on 08/29/2025 at 10:27 AM, the facility remained out of compliance at a level of no actual harm at a scope of isolated with a potential for more than minimal harm, that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems This deficient practice placed residents at risk for falls, injuries, dehydration, hospitalization, and death. Findings…

  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 · Gcited before2026-03-02 · 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 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 (Resident #1) reviewed for accidents hazards and supervision. The facility failed to ensure Resident #1's fall mat was in place, and the bed was in low position on 02/12/2026 at approximately 7:00 a.m., when he was found lying on the floor. The noncompliance was identified as PNC. The noncompliance began on 02/12/2026 and ended on 02/12/2026. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for falls with the possibility of injury, including fractures.Findings included: Record review of Resident #1's face sheet, dated 03/02/2026, reflected a [AGE] year-old male admitted to the facility on [DATE], diagnoses included unspecified dementia, unspecified severity, without…

  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
• Actual harm · Gcited before2025-01-26 · tag F0725 — failed to have enough nursing staff — isolated
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with a current accurate facility assessment for 9 of 11 residents ( Residents #1, #2, #3, #4 #5, #6, #7,#8 and #11). 1. The facility failed to ensure sufficient staff to provide Resident #6 needed care to prevent feelings of helplessness and pain from prolonged exposure to diarrhea for 3 hours while unable to obtain assistance. Residents #4 and #7 needed care including incontinent care and repositioning on 1/23/2025 for an unknown amount of time. 2. The facility failed to provide adequate staff to provide showers to Residents #1, #2,…

  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
• Actual harm · G2025-01-26 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  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 be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for for 9 of 11 residents ( Residents #1, #2, #3, #4 #5, #6, #7,#8 and #11). 1. The facility Administration failed to ensure an effective system to monitor for adequate staffing to provide Resident #6 needed care to prevent feelings of helplessness and pain from prolonged exposure to diarrhea for 3 hours while unable to obtain assistance. Residents #4 and #7 needed care including incontinent care and repositioning on 1/23/2025 for an unknown amount of time. 2. The facility Administration failed to ensure an effective monitoring system for adequate staffing to provide showers to Residents #1, #2, #3, #4 #5, #6, #7,#8 and #11 in compliance with their shower schedules. These failures placed residents at risk of inadequate supervision, an unsafe environment, skin breakdowns, falls and serious harm.…

  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
• Potential for harm · Ecited before2026-05-08 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  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 interviews, observation, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for two of eight (Resident #1 and Resident #2) residents reviewed for quality of care. 1. The facility failed to provide urostomy (a surgical procedure that creates an alternate pathway for urine to leave the body though an artificial opening on the abdomen) bags for Resident #1.2. The facility failed to provide tracheostomy (a surgical hole created through the neck to the trachea to assist with breathing) inner cannulas (a removable tube within a tracheostomy that helps keep the airway clear of mucus and debris) and Enemeez (a docusate sodium mini enema used to treat constipation) for Resident #2.These failures placed residents at risk of injury, infection, not receiving adequate care and services, and decreased quality of life.Findings include:Review of Resident #1's admission record, dated 05/06/2026, reflected a [AGE] year-old male…

  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 before2026-05-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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 care, consistent with professional standards of practice, to heal pressure injuries for one resident (Resident #2) out of four residents reviewed for pressure injuries.The facility failed to assess the wound to Resident #2's sacrum (the triangular area at the base of the spine fused between the hips) and acquire orders upon admission on [DATE] until 04/08/2026. This failure could place residents at risk of worsening wounds, infections and pain. Findings included:Review of Resident #2's admission record, dated 05/06/2026, reflected a [AGE] year-old female, admitted to the facility on [DATE] and discharged to the hospital on [DATE] with diagnoses that included: quadriplegia (a condition that causes paralysis in all four limbs), paralytic syndrome (a medical condition characterized by partial or complete loss of muscle function due to nerve or neurological impairment), and other reduce mobility. Review of Resident #2's comprehensive admission MDS,…

  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 before2025-12-22 · 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

  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 administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of two residents reviewed for medication administration, in that: The facility failed to ensure they administered Resident #1 a one-time order, dated 12/10/25, of 500 ml of Sodium Chloride 0.9%. Resident #1 instead received approximately 900 ml of Sodium Chloride 0.9%. Resident #1 was sent to the hospital for SOB, and returned the same day with a diagnosis of pneumonia, no fluid overload. The failure placed residents at risk for fluid overload, shortness of breath, blood pressure issues, physical injury to organ failure. Findings included: Record review of Resident #1's face sheet, dated 12/18/25, revealed a seventy-six-year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her admitting diagnoses included acute combined systolic (congestive) 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-09 · 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 ensure that residents received care, consistent with professional standards of care to prevent development or promote wound healing for one (Resident #1) of three residents reviewed for pressure ulcers. The facility failed to provide treatments on from 10/03/2025 thru 10/09/2025 to a skin tear on Resident #1's shin on the right lower leg. This failure could place residents at risk for worsening skin concerns leading to discomfort, pain, and potential infections. Findings included: Review of Resident #1's face sheet, dated 09/16/2025, reflected a [AGE] year-old male who was admitted on [DATE] with diagnoses which included type 2 diabetes (a chronic condition where the body either does not use insulin properly or does not produce enough insulin, leading to high blood sugar levels), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (memory loss, difficulty with communication,…

  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 before2025-12-09 · 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 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 keysfor 1 of 3 medication carts (Medication Cart #1) reviewed for medication storage. The facility failed to prevent Medication Cart #1 was locked and medications were secure 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 10/28/2025 at 2:37 AM revealed an unlocked medication cart #1 in front of one of one nurses' station. RN C was sitting behind the nurse's station. Interview on 10/28/2025 at 2:40 AM RN C stated she did not realize the medication cart was unlocked. She stated all medication carts were to be locked except when a nurse was obtaining medications from the cart. RN C stated if a resident did ingest medications the resident was allergic to there was a possibility 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-03 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #3 call light was within reach on 06/03/2025. This failure could place residents at risk of their needs not being met. Findings include: Record review of Resident #3's admission record, dated 06/03/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: unspecified dementia severity without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety (memory loss and thinking difficulties), major depressive disorder (mental health condition characterized by persistent feelings of sadness, loss of interest, and reduce…

  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 · Dcited before2025-06-03 · 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 interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 of 6 residents (Resident #1 and Resident #2) reviewed for bathing. The facility failed to provide showers to Resident #1 and Resident #2 in compliance with her shower schedule. This deficient practice could place residents at risk of decline in skin integrity and overall health. Findings included: Record review of Resident #1's admission record, dated 06/03/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: chronic obstructive pulmonary disease (lung disease that makes it difficult to breathe), hyperlipidemia (having too much fat in your blood, specifically too much cholesterol and or triglycerides), heart failure (the heart isn't able to pump enough blood to meet the body's needs), primary generalized osteoarthritis (cartilage in joints start…

  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 before2025-05-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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 that residents received care, consistent with professional standards of care to prevent development or promote wound healing for one (Resident #1) of three residents reviewed for pressure ulcers. The facility failed to provide treatments on 04/30/2025, 05/03/2025, and 05/05/2025 to a pressure ulcer on Resident #1's left heel. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections. Findings included: Review of Resident #1's face sheet, dated, 05/15/2025, reflected an [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included cellulitis of left lower limb (a bacterial skin infection affecting the deeper layers of the skin and the tissue beneath it in the left leg), pressure ulcer of left heel, stage 4 (the most severe type, characterized by deep tissue damage, potentially exposing muscles, tendons, or bone), type 2…

  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 · F2025-04-23 · 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 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 fiscal year 2025 for the first quarter (October 1, 2024, to December 31, 2024) reviewed for one of one facility administration reviewed. The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for October 1, 2024, to December 31, 2024. This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings Included: Record review of the CMS PBJ report for CMS FY Quarter 1 2025 (October 1, 2024-December 31, 2024) indicated the facility failed to submit data for the quarter. In an interview on 4/21/25 at 9:49 AM with ADM and RCN revealed ADM and RCN stated that they were aware 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-04-23 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  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 observations, 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 grooming, and personal and oral hygiene for 9 of 23 residents (Resident # 6, #15, #17, # 24, # 28, #45, # 66, #72, #76) reviewed for ADL care. The facility failed to provide showers as scheduled for Residents # 6, #15, #17, # 24, # 28, #45, # 66, #72, and #76. This failure could place residents who were unable to carry out ADLs independently, at risk of skin breakdown, pain, and infection. Findings included: 1. Record review of face sheet dated 4/22/25 for Resident # 6 reflected she was an [AGE] year old female admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia (a condition where the lungs fail to adequately oxygenate the blood, leading to low blood oxygen levels), dysphagia (difficulty swallowing food or liquids), type 2 diabetes (a long term condition in which the body has trouble…

  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

“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

$39,676 in federal fines across 4 penalties.

• $12,438 — penalty dated 2026-03-02
• $17,345 — penalty dated 2025-12-09
• $6,112 — penalty dated 2025-08-29
• $3,781 — penalty dated 2025-01-26

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 16 rows in the source record cover these 10 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.

What families pay in TX