Windsor Nursing and Rehabilitation Center of Morga

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.

48.5% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% 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 176 beds and averages 131.4 residents a day — about 75% occupied, or roughly 45 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 2.91 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.22 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.54 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 2.48 hrs/resident/day on weekends vs 3.08 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.23 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.

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

Inspection trend

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.

26 citations, most serious first. The 17 most serious are shown; the remaining 9 are one tap away and print in full.

• Immediate jeopardy · Jcited before2023-12-16 · 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, record review, and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents 1 (Resident #1) of 5 reviewed for elopement. The facility failed to ensure Resident #1 was supervised for elopement, Resident #1 eloped on 12/09/2023 and was found approximately 1.3 miles from facility. Failed to care plan Resident #1's wandering, pacing, trash digging, schizophrenia behaviors, and drug seeking behaviors. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 12/09/2023 and ended on 12/11/2023. The facility corrected the non-compliance before the investigation began. This failure could place residents at risk of not receiving individualized interventions to promote appropriate supervision that could cause injury/serious injury/ or death. Findings include: Record review of Resident #1's face sheet dated 12/15/2023, documented a [AGE] year-old male admitted on [DATE] with diagnoses of…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2023-08-23 · 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 interview and record review, the facility failed to ensure the right of the residents to be free from abuse for 1 of 1 residents reviewed for abuse and neglect. The facility failed to ensure Resident #1 did not experience abuse from CNA B. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 07/25/23 and ended on 7/25/23. The facility corrected the non-compliance before the investigation began. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of face sheet dated 7/28/2023 revealed Resident #1 is a [AGE] year-old male with a diagnosis of cerebellar ataxia, altered mental status, cognitive communication deficit, muscle wasting, dysphagia and a need or personal assistance. 2. Record review of Resident #1s quarterly MDS accessed on 7/28/2023 indicate he had a BIMS score of 6, which indicates severe mental impairment. 3. Record review of Resident #1s care plan initiated…

  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 · Past Non-Compliance
• Immediate jeopardy · J2023-08-23 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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 implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, for 1 of 3 residents (Resident#1) reviewed for abuse and neglect, in that: The facility failed to ensure CNA A and CNA C immediately reported any alleged incidents of abuse to the abuse prevention coordinator. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 07/25/23 and ended on 7/25/23. The facility corrected the non-compliance before the investigation began. These failures placed residents at risk of further abuse by leaving an alleged perpetrator remain in contact with facility residents. The findings were: During a record review of Resident #1's face sheet it was revealed he is a [AGE] year old male with a diagnosis of cerebellar ataxia, altered mental status, cognitive communication deficit, muscle wasting, dysphagia and a need or personal assistance. Record review of…

  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 · Past Non-Compliance
• Actual harm · Gcited before2026-04-14 · 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, interview, and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for of 5 residents (Resident #2) reviewed for abuse, neglect, and exploitation.The facility failed to protect Resident #2 from physical abuse when Resident #1 hit Resident #2 multiple times in the head and fell to the floor with him on 03/29/2026.These failures could place residents at risk for physical and/or psychological harm or injury.The findings included:1. Record review of Resident #1's face sheet, dated 04/09/2026, revealed a [AGE] year-old male with an admission date of 06/28/2024. Resident #1's diagnoses included Unspecified Dementia (a group of symptoms affecting memory, thinking and social abilities) and a history of Transient Ischemic Attack with Cerebral Infarction (a blockage or disruption of blood flow to the brain).Record review of Resident #1's Quarterly MDS assessment, dated 02/27/2026, revealed a BIMS score of 03, which indicated severely impaired…

  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
• Actual harm · G2026-04-14 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the residents' medical, nursing, and psychosocial needs for 1 (Resident #1) of 5 residents reviewed for person-centered care plans:The facility failed to recognize, develop, and implement a care plan and care plan interventions with measurable timeframes and objectives to address Resident #1's aggressive behaviors prior to his physical aggression incident on 03/29/2026.These failures could affect residents by placing them at risk of not being provided with the necessary care and services to address their needs. The findings included:Record review of Resident #1's face sheet, dated 04/09/2026, revealed a [AGE] year-old male with an admission date of 06/28/2024. Resident #1's diagnoses included Unspecified Dementia (a group of symptoms affecting memory, thinking and social abilities), and a history of Transient Ischemic…

  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
• Actual harm · Gcited before2026-04-14 · 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 observation, interview, and record review, the facility failed to ensure residents' environment remains as free of accidents and hazards as possible for 1 of 5 residents (Resident #3) reviewed for abuse, neglect, and exploitation.The facility failed to protect Resident #3 from neglect when the AA failed to apply her smoking apron, and Resident #3 received a cigarette burn on 03/19/2026.These failures could place residents at risk for physical and/or psychological harm or injury.The findings included:Record review of Resident #3's face sheet, dated 04/10/2026, revealed a [AGE] year-old female with an original admission date of 02/15/2024, and a current admission date of 06/11/2024. Resident #3's diagnoses included Type 2 Diabetes (a chronic condition which affects how your body metabolizes sugar [glucose], leading to high blood sugar levels and various health complications) and Dementia with other behavioral disturbances (a condition which affected memory, thinking, and the ability to perform daily…

  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 before2025-03-27 · 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 interview and record review the facility failed to ensure residents' environment remained as free of accident hazards as is possible; and residents received adequate supervision and assistance devices to prevent accidents for one 1 of 5 residents (Resident #9) reviewed for accident hazards. The facility failed to ensure that on 12/16/24 the PTA supervised and did not leave Resident #9 unattended in her wheelchair which allowed Resident #9 to fall out of the wheelchair onto the floor where she sustained a hematoma (a closed wound where blood collects and causes swelling because it cannot drain out) above and a laceration (cut) next to her left eyebrow. This failure could result in residents not receiving appropriate supervision leading to falls, injuries, or hospitalization. The findings included: Record review of Resident #9's admission record reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (a condition in which the blood flow to the brain…

  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 · D2026-04-14 · tag F0567 — failed to protect residents' money held by the home — isolated
  Honor the resident's right to manage his or her financial affairs.
  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 manage the personal funds deposited by residents for 1 (Resident #4) of 5 residents reviewed for residents' rights.The facility failed to ensure Resident #4 had access to his personal funds upon request in a timely manner on 04/03/2026.This failure could place residents whose funds were managed by the facility without access to their funds deposited within the facility.The findings Included: Record review of Resident #4's face sheet dated 04/10/2026 revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] with a readmission on [DATE]. Resident #4's admitting diagnosis was Transient Cerebral Ischemic Attack (a mini stroke which occurred when there was a temporary interruption of blood flow to the brain).Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, which indicated intact cognition. Record review of Resident #4's care plan, initiated 08/13/2024, revealed Resident #4 was…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-07-08 · 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 significant medication errors for 5 of 10 residents (Resident #23, Resident #47, Resident #66, Resident #74, and Resident #82) reviewed for medication errors. 1. The facility failed to ensure LVN C did not document NA in place of Resident #23's blood pressure and pulse when her blood pressure altering medication was administered on 06/03/25, 06/06/25, 06/07/25, 06/08/25, 06/16/25, 06/25/25, 06/26/26, 07/06/25, 07/07/25, and 07/08/25. The facility failed to ensure LVN C did not document NA in place of Resident #23's BP, temp, pulse, resp, and O2 sats on 06/07/25, 06/16/25, 06/25/25, 06/26/25, 07/04/25, 07/05/25, and 07/06/25 when vital signs were to be documented on every day shift on Saturday (04/12/25 to 06/09/25) then every shift (began 06/13/25) per the two physician's orders. The facility failed to ensure LVN P did not document X or NA in place of Resident #23's BP, temp, pulse, resp, and O2 sats on 06/13/25, 06/14/25,…

  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 · D2025-07-08 · tag F0559 — isolated
  Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
  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 one (Resident #70) of one resident the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. The facility did not provide Resident #70 with a written notice prior to a room change or the right to refuse on 03/27/25. This deficient practice could place residents at risk for being displaced without notice and/or reason to accommodate other individuals.Record Review of Resident #70's Face Sheet dated 07/07/2025 revealed a [AGE] year-old male re-admitted [DATE] with diagnoses including Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves) Quadriplegia (is paralysis that affects the ability to voluntarily move the upper and lower body), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) adult failure to thrive generalized anxiety disorder, and major depressive…

  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 · D2025-07-08 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who required dialysis received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #47) reviewed for Dialysis fistula assessment and care. The facility failed to ensure the nurses knew how and were performing the proper technique for assessing Resident #47's dialysis fistula (vascular access used in hemodialysis, which was a treatment for patients with kidney failure) for thrill (a vibration felt over the fistula or shunt) and bruit (swooshing sound cause by blood flow through the fistula or shunt). This deficient practice and failure could place residents at risk for a blockage and/or stenosis (narrowing of the veins and/or arteries) of the fistula site.Record review of Resident #47's face sheet, dated 07/08/2025, revealed a [AGE] year-old male with an original admission date of 09/30/2019, and a current admission date of 03/28/2025. Diagnoses included Alcoholic…

  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 · D2025-07-08 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were labeled and stored in accordance with currently accepted professional principles for 3 of 6 medication carts (2nd Floor Nurse Med-Cart A, 2nd Floor Treatment Cart, 3rd Floor Nurse Med-Cart B, and 3rd Floor Treatment Cart) reviewed for labeling and storage. The facility failed to properly label from 2nd Floor Nurse-Med-Cart-A a vial of insulin Glargine (a long-acting insulin used to treat Type 1 or Type 2 Diabetes), with an open or expiration date. The facility failed to dispose of the medication from 2nd Floor Treatment Cart a container of Hemorrhoidal Pads (a pad used to treat hemorrhoids) 50% which had expired on 03/22/2025. The facility failed to dispose of the medication from 3rd Floor Nurse-Med-Cart-B a card of Promethazine (a medication used to treat nausea) 25 MG which had expired on 05/21/2025. The facility failed to keep the 3rd Floor Treatment Cart free from employee personal items on 07/07/2025 as evidenced by a large, personal, aluminum cup with a straw in it…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-08 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, staff and public in 2 (Elevator 1 and Elevator 2) of 3 elevators reviewed for environment. The facility failed to maintain 2 elevators used by residents, staff, and visitors free from offensive odors. This failure could affect all residents that used common areas and place them at risk for diminished quality of life due to the lack of a well-kept environment. During an observation throughout the day beginning on 07/07/25 08:33 AM, this surveyor smelled a strong foul odor on both Elevator 1 and Elevator 2 most of the day. During an observation throughout the day beginning on 07/08/25 08:10 AM this surveyor smelled a strong foul odor on both Elevator 1 and Elevator 2. In an interview on 07/07/25 at 08:45 AM, a visitor who wished to remain anonymous stated the elevators always smelled foul and smelled of urine and feces. In an interview on 07/07/25 at 03:47 PM, the MDS Coordinator agreed that Elevator 1 and Elevator 2 smelled bad and stated they did not…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-27 · 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, interview and record review, the facility failed to ensure the right to be free from abuse for one (Resident #62) of two residents reviewed for abuse. The facility failed to ensure Resident #62 was free from abuse. On 10/24/24, Resident #60 hit Resident #62 in the head with a grabber because Resident #62 would not stop touching it. This failure could place residents at risk for abuse and psychological harm. Findings included: Record review of Resident #60's face sheet revealed a [AGE] year-old male with an admission dated of 06/20/19. Diagnoses included dementia (disease that results in loss of memory, language problem, problem-solving and other thinking abilities that are severe enough to interfere with daily life), muscle wasting, high blood pressure, depression, mood disorder, and abnormalities of gait and balance. Record review of Resident #60's Annual MDS, dated [DATE], reflected a [AGE] year-old male who admitted on [DATE]. His BIMS score of 15 indicated the resident had no 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-27 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  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 alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, are reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 2 of 3 Residents (Residents #62 and #61) reviewed for Abuse, and Injury of unknown source. 1. The facility did not report an allegation of abuse per facility policy to the Administrator regarding Resident #62 on 02/24/25 until 02/28/25. 2. The facility failed to ensure CNA ZZ reported an allegation of injury of unknown sources per facility policy to the Administrator…

  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 · D2025-03-27 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  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 that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for two residents (Resident #3 and Resident #61) of 20 residents whose care plans were reviewed, in that: 1) Resident #3's comprehensive care plan was not revised to reflect Resident #3 had a history of trying to give money to residents and staff. 2) Resident #61's comprehensive care plan was not revised to reflect interventions for Resident #61 who had a history of falls. These failures could place residents at risk for inadequate care, accidents, and injuries. The findings included: 1.Record review of Resident #3's face sheet dated 03/26/25 reflected an [AGE] year-old-female with an original admission date of 06/27/24. Diagnoses included Alzheimer's Disease (brain disorder that affects memory, thinking, behavior and everyday skills) and depression (mood disorder that causes persistent feelings of sadness and loss of interest).…

  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 · Ecited before2024-06-18 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and under proper temperature controls on 2 of 6 treatment/medication carts and 3 of 3 medication storage rooms reviewed for storage of drugs. 1. The 200-floor treatment/medication cart was left unlocked by the nurse's station with the drawers facing outward. 2. 300 floor treatment/medication cart was left unlocked outside room [ROOM NUMBER] with its back against the wall and drawers facing the hallway. 3. The temperature log for the medication storage refrigerator in the 400 floor medication storage room did not have a temperature recorded for 06/15/24 or 06/16/24 and the refrigerator was not clean. 4. The temperature log for the medication storage refrigerator in the 300 floor medication storage room did not have a temperature recorded for 06/09/24 AM or 06/17/24 AM. 5. The temperature log for the medication storage refrigerator in the 200 floor medication storage room did not have 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

“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

$32,353 in federal fines across 3 penalties.

• $16,350 — penalty dated 2026-04-14
• $8,385 — penalty dated 2023-12-16
• $7,618 — penalty dated 2023-08-23

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 WELLSENTIAL HEALTH — 67 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 35 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted.

11 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 72% 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. 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