The Lennwood Nursing and Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

59.3% 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 33 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 39.1% 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 23 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 124 beds and averages 63.8 residents a day — about 51% occupied, or roughly 60 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.90 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.20 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.61 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 2.41 hrs/resident/day on weekends vs 3.10 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.24 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 69% is well above 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.

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

• Immediate jeopardy · Jcited before2025-05-07 · 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, record review, and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 6 residents reviewed for quality of care. 1. The facility failed to ensure Resident #1, who had a history if eloping and wore a wandergaurd, was provided with adequate supervision to prevent him from eloping from the facility on 03/28/25. The facility concluded Resident #1 eloped through the facility's exit door that did not alarm when opened. 2. The facility failed to complete an elopement assessment for Resident #1 prior to his elopement on 03/28/25 The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 03/28/25 and ended on 04/01/25. The facility had corrected the non-compliance before the survey began. These failures placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · K2024-07-01 · tag F0580 — failed to tell family and doctor about changes — pattern
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately consult with the residents' physicians when there was a significant change in the resident's physical, mental or psychosocial status in either life-threatening conditions or clinical complications; or when there is a need to alter treatment significantly, for two (Residents ##3 and #4) of five residents reviewed for resident rights. 1. The facility failed to consult with the physician when Resident #3 had a change in condition which resulted in a dangerously low blood sugar of 40. Resident #3 died at the facility unexpectedly within 24 hours of his change of condition. 2. The facility failed to notify the physician [MD O] or physician extender [NP M] of Resident #4's x-ray results when he had a change in condition on [DATE]. The x-ray results indicated there were abnormal findings which included widespread bilateral nodular lung opacities and small right pleural effusion opacities which was consistent with severe pulmonary edema or…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-07-01 · 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 interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for two (Residents #3 and #4) of five residents reviewed for quality of care. 1. The facility failed to ensure Resident #3 was accurately assessed, monitored, and treated for a change of condition he had with a blood sugar of 40 at 8:15 AM during the morning shift on [DATE]. There was no documented evidence the facility monitored the residents' change of condition after that shift. Resident #3 died later that night on the overnight shift around 2:05 AM with a cause of death as unknown. 2. The facility failed to ensure Resident #4 was accurately assessed, monitored and treated for a change in condition on [DATE]. The facility had no documented evidence they monitored the resident after the initial change was observed. The NP was notified and ordered a chest x-ray. The x-ray results indicated there were abnormal findings which included…

  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 · E2026-06-30 · tag F0628 — pattern
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  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 complete a discharge summary for 4 of residents (Resident #1, Resident #2, Resident #3, Resident #4) 4 residents reviewed for discharge summaries. 1. The facility failed to ensure 4 of residents (Resident #1, Resident #2, Resident #3, Resident #4) discharged the facility with a discharge summary that included an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions to ensure that care is coordinated and the resident transitions safely from one setting to another. This failure could place residents at risk for not receiving appropriate and timely care due to confusion among various facilities, agencies, practitioners, and caregivers involved with the resident's care.Findings Included:Record review of Resident #1's Face Sheet, printed 06/30/26, revealed the [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with a primary diagnosis 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 no plan of correction
• Potential for harm · Dcited before2026-06-16 · 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

  Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (300 Hall) out of 1 hallways reviewed for accidents and hazards. 1. The facility failed to ensure that 1 of 1 mechanical lift on the 300 Hall was locked, secured and stored in a secure designated area when not in use. 2. CNA B did not remove the unlocked and unsecured mechanical lift parked on the hallway of the 300 Hall in between residents' rooms. This failure could place residents, visitors and staff at risk of falls and/or injuries. Findings Included: An observation on 06/16/26 at 11:16 AM revealed one unlocked and unsecured mechanical lift parked on the hallway on the 300 Hall in between residents rooms. There were not any residents observed in the hallway during the observation. An observation on 06/16/26 at 11:32 AM revealed one unlocked and unsecured mechanical lift parked on the hallway on the 300 Hall in between resident's rooms. There were not any residents observed in the hallway during the observation. An…

  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 · E2025-12-11 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident rights to a comfortable, homelike environment, with accommodation of needs for 6 of 12 residents (Resident #43, Resident #60, Resident #39, Resident #62, Resident #63, Resident#56) reviewed for residents' rights.1.The facility failed to ensure the temperature in Resident #60's room was maintained at a safe and comfortable range of 71 to 81 degrees on 9/23/25. The room temperature was 82 degrees Fahrenheit.2.The facility failed on 09/23/2025 to ensure the call light system was accessible to a resident, the call light was lying on the floor in the shared residents' toilets located inside the residents' rooms on 9/23/25 for Resident #43, Resident # 60, Resident #39, and Resident #62.3. The facility failed to ensure Resident #63's and Resident #56's call light was within reach on 09/23/25. This failure could place residents at risk of an uncomfortable environment ,not having a means of directly contacting caregivers in an…

  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 · E2025-12-11 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  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 with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 2 of 2 (Resident #34, and Resident #45) residents reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #34 and Resident #45's contractures to their left hands on 09/23/25. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. 1-Record review of Resident #34's Quarterly MDS, dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE], and readmitted on [DATE]. Resident #34 had diagnoses of hypertension (elevated blood pressure), cerebrovascular accident (It is a serious medical condition that occurs when the brain is damaged due to a lack of blood flow, either from a blocked blood vessel or a ruptured one),…

  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 before2025-12-11 · 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 observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 (Resident #6, #14, #30) of 7 residents reviewed for accidents and hazards.1. The facility failed to ensure Resident #14 had a wanderguard and the placement and functioning of the device was monitored and documented in his medical record. 2. The Administrator and DON failed to implement a system to ensure residents (Resident #6, #14, and #30) at risk for wandering/elopement were monitored and documented in the resident's treatment administration record and that staff were following current physician orders for wanderguard placement. These failures could place the residents at risk for elopement and serious harm. Findings included:1. Review of Resident #14's face sheet undated reflected Resident #14 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Dementia (loss of memory, language, problem-solving and other…

  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 · E2025-12-11 · 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, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 of 6 residents (Resident #53) reviewed for storage of medications.The facility failed to ensure Resident #53's Econazole Nitrate Cream (treatment for skin infection) labeled topical ointment, was secured, and not left at the bedside.This deficient practice could place residents at risk for loss of biologicals, overuse of medication, and not receiving the therapeutic benefit of the medication. Findings included:Record review of Resident #53's admission MDS, dated [DATE] reflected an [AGE] year-old male who was admitted to the facility on [DATE], and readmitted on [DATE]. Resident #53 had diagnoses of hypertension (Elevated blood pressure), and Alzheimer's Disease (a progressive brain disorder that causes memory loss, cognitive decline, 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 · D2025-12-11 · 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 a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to meet the resident's highest practicable physical, mental, and psychosocial wellbeing for 6 (Residents #14, #8, #6, #29, #30 and #37) of 24 residents reviewed for care plans.1. The facility failed to develop a comprehensive care plan for Residents #8 and #14 who were at risk for elopement/wandering.2. The facility failed to develop a Kardex for Residents #6, #8, #14, #29, #30 and #37 at risk for elopement/wandering.These failures place residents at risk of not having their individualized needs meet, preventative measures and interventions in place to prevent elopements. Findings included:1. Review of Resident #14's face sheet undated reflected Resident #14 was a [AGE] year-old male admitted to the facility on [DATE]…

  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 before2025-12-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 4 (Resident #37, Resident #34, Resident #45, and Resident #60) of 12 residents reviewed for personal care. The facility failed to ensure: 1- Resident #37's nails were trimmed and without jagged edges. 2- Resident #60's nails were trimmed and cleaned. 3- Resident#34's nails were trimmed and cleaned. 4- Resident#45's nails was trimmed and without jagged edges. This failure could place residents who require staff assistance at risk of dermatitis (inflammation of the skin), infections, and low self-esteem.1-Record review of Resident #37's care plan reflected he was at risk of impairment to his skin's integrity due to decreased mobility and incontinence, interventions included to avoid scratching and keep fingernails short, dated initiated 10/04/25. An observation and interview on 09/23/25 at 10:20 AM,…

  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 before2025-12-11 · 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 observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 (300-400-600-Hall cart) medication carts reviewed for pharmacy services. The facility failed to ensure expired medication, was removed from the 300-400-600-Hall medication cart. This failure could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose, and/or contamination from expired supplies.Findings included:Observation on 09/23/25 at 09:21 AM of the 300-400-600-Hall medication cart revealed:-Two boxes of Latanoprost Ophthalmic Solution 0.005 % (Glaucoma ) with open date of 08/09/25-One box of Dorzolamide hcl 2% (Glaucoma ) with open date of 08/09/2025.-One box Timolol maleate 0.5% (glaucoma) with open date of 08/09/2025. -Two boxes of Artificial tears with open date of 08/13/25. During an interview on 09/23/25 at 10:23 AM, LVN I stated all the nurses…

  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 before2025-12-11 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 4 residents (Resident #43) observed for infection control. CNA M failed to perform hand hygiene and change gloves while providing incontinence care to Resident # 43. This failure could place residents at risk for infection.Findings included:Record review of Resident #43's Quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE], and readmitted [DATE] with the diagnoses of hypertension (elevated blood pressure), type 2 diabetes (elevated blood sugar), and cerebrovascular accident (occurs when blood flow to the brain is interrupted, leading to brain damage). Resident #43 had a BIMS score of 06, which indicated severe cognition impairment. Further review revealed urinary continence/ bowel continence were coded as frequently incontinent. Record review of Resident #43's care plan…

  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

“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

$29,969 in federal fines across 2 penalties.

• $9,113 — penalty dated 2025-05-07
• $20,856 — penalty dated 2024-07-01

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 PARAMOUNT HEALTHCARE — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 14 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 73% 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