The Highlands Guest Care Center

Location & what’s nearby

Open in Google Maps ↗ · Directions ↗ · Larger map ↗

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.

38.3% 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 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 16.7% 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 30 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 0.52 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 116 beds and averages 72.0 residents a day — about 62% occupied, or roughly 44 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 3.32 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 2.97 hrs/resident/day on weekends vs 3.46 on weekdays — 14% thinner on weekends. RN hours go from 0.46 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

25 citations, most serious first. The 14 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · K2025-04-14 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews,observation and record reviews, the facility failed to ensure resident has the right to be free from neglect for one (Resident #1) of eight residents reviewed for abuse neglect. On 2/21/2025, CNA A transferred Resident #1 without a gait belt from the shower chair to the bed. As a result, Resident #1 suffered a fracture to the left distal diaphysis of the tibia (lower area of the shin bone). Oversight and monitoring of direct care staff (nurse aides), was not addressed. CNA A transferred Resident #1 inappropriately on 2/21/25 causing a left lower extremity fracture, was not retrained and or monitored, and then CNA A transferred Resident #1 inappropriately on 04/07/25 causing a right lower extremity fracture. CNA A was aware Resident #1 required two staff to transfer but transfered the resident alone. This failure resulted in an Immediate Jeopardy situation on 04/10/2025. While the IJ was removed on 4/14/25, the facility remained out of compliance at a severity level of no actual harm with…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-04-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of nine residents reviewed for accidents and supervision. On 2/21/2025, CNA A transferred Resident #1 without a gait belt from the shower chair to the bed. As a result, Resident #1 suffered a fracture to the left distal diaphysis of the tibia (lower area of the shin bone). Oversight and monitoring of direct care staff (nurse aides), was not addressed. CNA A transferred Resident #1 inappropriately on 2/21/25 causing a left lower extremity fracture, was not retrained and or monitored, and then CNA A transferred Resident #1 inappropriately on 04/07/25 causing a right lower extremity fracture. This failure resulted in an Immediate Jeopardy situation on 4/10/2025. While the IJ was removed on 4/14/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm due to…

  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 · K2025-04-14 · tag F0697 — failed to manage pain — pattern
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of eight residents reviewed for abuse and neglect. 1. The facility failed to ensure Resident #1 did not experience additional pain after sustaining a fracture on 2/21/2025 to the left distal diaphysis of the tibia (lower area of the shin bone) and was not transferred to the hospital until 2/26/2025 (five days later). 2. The facility failed to ensure Resident #1's pain was accurately assessed and documented. This failure resulted in an Immediate Jeopardy situation on 04/10/2025. While the IJ was removed on 04/14/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm actual harm due to staff needing more time to monitor the effectiveness for the plan of removal for neglect. This failure…

  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 · K2025-04-14 · tag F0777 — pattern
  Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
  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 promptly notify the ordering physician of results which fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for one (Resident #1) of eight residents reviewed for notification of changes. 1. The facility failed to notify and consult with Resident #1's physician on 2/21/2025 when x-ray results were received revealing Resident #1 had a fracture to the left distal diaphysis of the tibia (lower area of the shin bone). Resident #1 was not sent to the hospital until five days later, on 2/26/2025. 2. The facility failed to notify and consult with Resident #1's physician on 4/07/2025 when x-ray results were received revealing Resident #1 had an oblique fracture (a bone break that occurs at an angle to the bone's long axis) to the right distal diaphysis of the tibia (lower area of the shin bone). Resident #1 was not sent to the hospital until 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 · Dcited before2026-06-10 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plan development. The facility failed to ensure Resident #1's comprehensive care plan included a plan of care for ADLs. This failure could place residents at risk of not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. The findings included: Record review of the MDS dated [DATE] indicated Resident #1 was a 70-years-old female and was admitted on [DATE] with diagnoses including hypertension (elevated blood pressure), non-Alzheimer's dementia (a broad group of progressive brain disorders that cause cognitive decline severe enough to impact daily life, but are not caused 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
• Potential for harm · Dcited before2025-12-30 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents' right to be treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident #38) reviewed for respect and dignity in that: The facility failed to ensure RN A provided privacy by leaving the door open and not pulling privacy curtain, exposing Resident #38's abdomen while administering the medications through gastroenterology tube (feeding tube). This failure could place residents at risk of emotional distress and low self-esteem. Findings included: Record review of Resident #38's significant change MDS assessment, dated 12/19/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included: Cancer (destroying tissue), multiple sclerosis (neuromuscular disease), aphasia (unable to speak), dysphagia (unable to swallow), and…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-14 · tag F0908 — failed to keep essential equipment working — pattern
  Keep all essential equipment working safely.
  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 and interview the facility failed to ensure all patient care equipment was in safe operating condition for three (Resident #1, Resident #2, and Resident #3) of eight residents reviewed for safe operating patient care equipment. 1. The facility failed to ensure Resident #3 had brakes on the foot of his bed. 2. The facility failed to ensure one brake on Resident #1's bed was able to lock. 3. The facility failed to ensure Resident #2's bed had a working remote control. These failures could place residents at risk of living in an unsafe and un-homelike environment. Findings included: 1. Record review of Resident #3's Annual MDS revealed Resident #3 was a [AGE] year-old male admitted to the facility on [DATE]. Section C of the MDS assessment revealed a BIMs score of 12 (indicated mildly impaired cognition). Section I of the MDS revealed Resident #3 had diagnoses of muscle weakness, morbid obesity (overweight), and anxiety disorder. Record review of Resident #3's care plan with a revision date 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-02-19 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents, (Resident #1) reviewed for care plans. 1. The facility failed to follow the care plan dated 07/05/24 when staff failed to ensure a pillow was always under Resident #1's feet who had a DTI to the heel, while she was in the bed on 02/19/25. This failure could place residents at risk of not receiving the necessary care and services. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female, with an initial admission date of 04/06/23, and a re-admission date of 02/18/25. Resident #1 had a diagnosis of non-traumatic acute subdural hemorrhage (blood leaks between the brain and the skull), 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-19 · 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 observation, record review and interview, the facility failed ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers from developing 1 (Resident #1) of 6 residents reviewed for pressure ulcers. The facility failed on 02/19/25 to use a pillow under Resident #1's heels, at all times, to offload Resident #1's heels to prevent pressure ulcers or skin breakdown. This failure could affect residents at risk for pressure ulcers of developing new or worsening existing pressure ulcers. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female, with an initial admission date of 04/06/23, and a re-admission date of 02/18/25. Resident #1 had a diagnosis of non-traumatic acute subdural hemorrhage (blood leaks between the brain and the skull), Type 2 Diabetes (body does not use insulin properly or produce enough insulin), Hypothyroidism (thyroid gland does not produce enough thyroid hormone), Muscle weakness, Chronic Kidney…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-10-10 · 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 observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for five (Resident #13, Resident #39, Resident #49, Resident #70, and Resident #71) of twenty-seven residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light was in reach and accessible for Resident #13, Resident #39, Resident #49, Resident #70, and Resident #71. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #13 Review of Resident #13's Face Sheet, dated 10/08/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #13's pertinent diagnoses included paraplegia (paralysis of the legs and lower part of the body) and muscle weakness. Review of Resident #13's Quarterly MDS Assessment, dated 07/10/2024, reflected the resident…

  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 before2024-10-10 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for eight (Resident #10, Resident #13, Resident #44, Resident #49, Resident #56, Resident #61, Resident #80, and Resident #84) of eighteen residents observed for Infection Control. 1. The facility failed to ensure that CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #49. 2. The facility failed to ensure that CNA E changed her gloves and performed hand hygiene while providing incontinent care to Resident #80. 3. The facility failed to ensure that LVN B sanitized the blood pressure cuff in between Resident #44, Resident #56, Resident #61, and Resident #84. 4. The facility failed to ensure that LVN C sanitized the blood pressure cuff in between Resident #10 and Resident #13. These…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-10 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide the right to personal privacy which includes accommodations during personal care for one (Resident #13) of thirteen residents reviewed for Privacy. The facility failed to ensure LVN D closed Resident #13's door while performing wound care. This failure could place the residents at risk of not having their personal privacy maintained during medical treatment. Findings included: Review of Resident #13's Face Sheet, dated 10/08/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #13's pertinent diagnoses included paraplegia (paralysis of the legs and lower part of the body) and injury to Achilles tendon (connective tissue that connects the calf to the heel bone). Review of Resident #13's Quarterly MDS Assessment, dated 07/10/2024, reflected the resident had an intact cognition with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had an injury to Achilles tendon. 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #13) of eight residents reviewed for Respiratory Care. The facility failed to ensure that Resident #13's BiPAP (Bilevel Positive Airway Pressure: machine used to deliver pressurized air through a mask to keep airways open) mask was stored properly. This failure could place the resident at risk for respiratory infection and not having her respiratory needs met. Findings included: Review of Resident #13's Face Sheet, dated 10/08/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #13 was diagnosed with acute respiratory failure and obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Review of Resident #13's Quarterly 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 · E2023-08-24 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 3 of 5 resident rooms (Resident #13, 29, and 84) observed for a clean environment. The facility failed to ensure that resident rooms were cleaned daily, and in accordance with the facility's Housekeeping Workers' Checklist. This deficient practice could negatively impact the facility's ability in preventing the spread of disease-causing organisms in residents' living areas. Findings include: Observation on 08/22/23 at 11:35 AM, in Resident # 84's room revealed the bathroom in the resident's room had dried up Fecal matter on the top left side of the toilet. The bottom portion of the toilet had dark dirt stains on around it. An interview with Resident # 84 (BIMS: 15) revealed, she had asked two CNAs (could not remember names) to clean the toilet earlier in the morning, after her roommate had messed it up and no one had yet to clean the toilet. Resident #84…

  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

$47,726 in federal fines across 1 penalty.

• $47,726 — penalty dated 2025-04-14

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.

Who owns this facility

CMS files one row per role, so the 11 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

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