University Rehabilitation Center

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.

52.5% 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 49 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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 146 beds and averages 116.2 residents a day — about 80% occupied, or roughly 30 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 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 2.98 hrs/resident/day on weekends vs 3.51 on weekdays — 15% thinner on weekends. RN hours go from 0.39 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 88% is well above the national median of 45%. 4 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

Inspection deficiencies

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

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

38 citations, most serious first. The 15 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-09-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one of thirteen residents (Resident #12) reviewed for accidents and hazards.The facility failed to ensure Resident #12 received the appropriate supervision to prevent elopement from the facility on 6/23/2025 and 07/13/2025.The non-compliance was identified as PNC on 09/11/25 and the IJ template was provided the facility on 09/11/25 at 3:10 PM. The noncompliance began on 07/13/2025 and ended 07/13/2025. The facility corrected the non-compliance before the survey began.These failures could place the residents at risk of serious harm, injury and death from wandering outside the facility in unfamiliar surroundings. . Findings include: Record review of Resident #12's Face Sheet, dated 09/11/2025, reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #12 had diagnoses which included moderate dementia…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2024-02-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Residents #11 and #49) of 7 residents reviewed for quality of care. 1. LVN D failed to order xrays for Resident #11 after she fell on [DATE] and complained of right-side pain. The xrays were not completed until the next day 12/17/23 the resident was diagnosed with fractures of the 8th to 10th ribs. 2. The facility failed to assess and document Resident #49's injury to her right ankle on 01/23/24, when therapy heard an audible sound when he attempted to put her shoe back on. On 01/24/24 it was noticed by staff that Resident #49 had swelling and bruising to her right ankle. Resident #49 was diagnosed with a right ankle fracture and underwent surgery. An Immediate Jeopardy was identified on 02/27/24. While the Immediate Jeopardy was removed on 02/28/24, the facility remained out 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 · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-02-28 · tag F0776 — isolated
  Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
  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 provide radiology or other diagnostic services to meet the needs of its residents in a timely manner for 2 (Resident #11 and #49) of 7 residents reviewed for radiology services. 1. LVN D failed to order xrays for Resident #11 after she fell on [DATE] and complained of right-side pain. The xrays were not completed until the next day 12/17/23 and the resident was diagnosed with fractures of the 8th to 10th ribs. 2. The facility failed to obtain timely radiology services on 01/23/24, after the Physical Therapist reported to the nurse that Resident #49 had an audible sound to her right ankle and was noted to be in an unusual position. The morning of 01/24/24, the resident was noted to have swelling and after xrays were ordered, she was diagnosed with a right ankle fracture and was sent to the hospital where she underwent surgery. An Immediate Jeopardy was identified on 02/27/24. While the Immediate Jeopardy was removed on 02/28/24, the facility…

  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
• Immediate jeopardy · Jcited before2022-12-02 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status and a need to alter treatment significantly for 2 (Resident #32 and #29) of 8 residents reviewed for physician notification. The facility failed to ensure: 1. LVN B immediately notified Resident #32's physician when Resident #32, who did not have a history of shortness of breath complaints, complained of not being able to breathe and requested two breathing treatments the night of 11/28/22. Resident #32 was discovered on 11/29/22 unresponsive and not breathing. CPR was preformed but she was pronounced dead at the facility on 11/29/22. 2. LVN A notified Resident #29's physician when she complained of pain and numbness to both her arms, pain level 9 out of 10 (10 being the worst) and stated that was how she felt the last time she had a stroke. An Immediate Jeopardy (IJ) was identified on 11/30/22 at 5:36 PM and the ADM, DON, and the RNC…

  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 · Jcited before2022-12-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Resident #32 and Resident #29) of 8 residents reviewed for quality of care. The facility failed to ensure: 1. Resident #32 was appropriately assessed, monitored, and care plans were followed when Resident #32, who did not have a history of shortness of breath complaints, complained of not being able to breathe and requested two breathing treatments the night of 11/28/22. Resident #32 was discovered on 11/29/22 unresponsive and not breathing. CPR was preformed but she was pronounced dead at the facility on 11/29/22. 2. Resident #29 was appropriately assessed and monitored when she complained of pain to both her arms, pain level 9 out of 10 (10 being the worst) and stated that was how she felt the last time she had a stroke. Resident #29 was difficult 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
• Potential for harm · D2026-04-23 · 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

  Based on interview and record review, the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for one (Incident #1079379) of four incidents reviewed for reporting of alleged violations. The Administrator failed to report the results of an investigation within five working days to the State Survey Agency. This failure could place residents at risk of not receiving timely and appropriate responses to alleged violations of abuse, neglect, and/or exploitation.Findings included: Record review completed on 04/23/26 at 9:00AM of the TULIP (Texas Unified Licensure Information Portal) system revealed that no Provider Investigation Report (Form 3613-A) had been filed for Incident #1079379 (no named/identified residents). The facility had filed the Facility Reported Incident and CII Self-Report Template (the initial reports) with the State Survey Agency on 03/27/26. Record review of the Provider…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-23 · 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 interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's 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 two (Resident #1 and Resident #2) of seven residents reviewed for comprehensive care plans. 1.) The facility failed to ensure that Resident #1's comprehensive care plan identified nebulizer treatments as an intervention for respiratory care. 2.) The facility failed to ensure that Resident #2's comprehensive care plan identified oxygen therapy as an intervention for respiratory care. This failure could place residents at risk of not receiving proper care and services due to inaccurate care plans.Findings included: 1.) Record review of Resident #1's Face Sheet, dated 04/23/26, reflected he was an [AGE] year-old male, who was originally admitted to 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-23 · 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 establish and maintain respiratory care including oxygen services, including the safe handling, humidification, cleaning, storage, and dispensing of oxygen for two (Resident #1 and Resident #2) of seven residents reviewed for respiratory care. 1.) The facility failed to ensure that Resident #1's nebulizer mask and mouthpiece were bagged in a plastic bag. 2.) The facility failed to ensure that Resident #2's oxygen tubing/nasal cannula were bagged in a plastic bag. These failures could place residents receiving respiratory therapy at risk of health-associated infections.Findings included: 1.) Record review of Resident #1's Face Sheet, dated 04/23/26, reflected he was an [AGE] year-old male, who was originally admitted to the facility on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia (a sudden, life-threatening inability to maintain oxygen levels, while chronic respiratory failure develops gradually,…

  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors for one (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1 received the correct dosage of levetiracetam (Keppra, and anti-epileptic drug/seizure medication) from 10/09/2025 to 11/26/2025. This failure could place residents at risk of medical complications not receiving the therapeutic effects of their medications.Findings included:Record review of a facility face sheet dated 12/10/2025 for Resident #1 reflected that she was a [AGE] year-old female who initially admitted to the facility on 08.08/2025 with diagnoses that included: TRAUMATIC SUBARACHNOID HEMORRHAGE WITHOUT LOSS OF CONSCIOUSNESS, SUBSEQUENT ENCOUNTER (bleeding in the brain), UNSTEADINESS ON FEET, and UNSPECIFIED CONVULSIONS (seizures).Record review of the Quarterly MDS assessment dated [DATE] for Resident #1 reflected that the resident had a BIMS score of 99 which…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-09-11 · 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 observation, record review and interview the facility failed to implement services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for ten (Resident # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) reviewed for care plans Based on observation, record review and interview the facility failed to implement services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for ten (Resident # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) reviewed for care plans The facility failed to ensure Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 were properly supervised while smoking in the smoking area of the facility. The facility failed to implement adequate supervision for Resident #1, #2, #3, #4,# 5, #6, #7, #8, #9, and #10 while smoking in the smoking area of the facility. 1. Record review of Resident #1's Face Sheet, dated 09/11/25, reflected she was an [AGE] year-old female admitted 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-11 · 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 of three residents (Resident #11) reviewed for respiratory care. The facility failed to ensure Resident 11's oxygen mask was properly stored in a bag when not in use on 09/11/25. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met.Findings include: Record review of Resident #11's Face Sheet, dated 09/11/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Acute Respiratory Failure (lack of oxygen) and Chronic Obstructive Pulmonary Disease (lung disease). Record review of Resident #11's Quarterly MDS assessment, dated 9/02/25, reflected he had a BIMS score of 12 (moderate cognitive impairment). For ADL…

  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 before2025-04-17 · 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 the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents for three of three residents (Residents #7, #26, and #198) reviewed for accidents and hazards. The facility failed to properly maintain wheelchair armrests for Residents #7, #26, and #198 These failures could place residents at risk for equipment that is in unsafe operating condition, which could cause injury. Findings included: 1. Record review of Resident #7's quarterly MDS assessment, dated 02/18/25 reflected a [AGE] year-old female who had been initially admitted to the facility on [DATE]. Resident #7 had diagnoses that included Cerebrovascular Accident (stroke), Alzheimer's Disease, Dementia, repeated falls, and unsteadiness on feet. Record review of Resident #7's plan of care, dated 02/25/2025, reflected goals and approaches to include wheelchair mobility for…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-04-17 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure dented cans were placed in a separate storage area. 2. The facility failed to ensure food items were discarded by the use by date. These failures could place residents at risk for food-borne illness and cross contamination. Findings Include: Observation of the refrigerator on 04/15/2025 at 9:47am revealed the following: -3 1-gallon milk with a use by date 04/08/2025. Observation of the dry storage on 4/15/2025 at 9:55am revealed the following: -1 6lb 10oz can of spaghetti sauce dated 12/30/2024 was dented on top right and top left. -1 6lb can of mushrooms dated 10/29/2024 was dented on front bottom and front left. -1 6lb 10oz can of pumpkin dated 3/10/2025 was dented on top right. -1 8lb 4oz can of apple jelly dated 4/14/2025 was dented on top back. Interview with the DM on 04/15/2025 at 11:15am she stated it 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-17 · 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 observation, interview and record review, the facility failed to ensure that each resident has the right to privacy to be treated with respect, personal body privacy, and dignity during wound care for 1 of 4 residents (Resident #15) reviewed for respect, privacy and dignity in that: Each resident has the right to privacy and confidentiality for all aspects of care and services. A nursing home resident has the right to personal privacy of not only his or her own physical body, but of his or her personal space, including accommodations and personal care. The facility failed to ensure Treatment Nurse A provided privacy when providing Resident #15 with wound care. The facility failed to ensure Physical Therapist provided privacy and dignity when the Physical Therapist announced in front of Resident #15 to Treatment nurse A that she needed to go and care for another resident's wound because it was leaking blood through the dressing. This failure could place residents at risk of emotional distress and low…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-17 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  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, interviews, and record reviews, the facility failed to ensure each resident was treated with a clean comfortable environment during care, to include clean linens to support their quality of life, recognizing each resident's individuality for 1 (Resident #15) of 4 residents. The facility failed to ensure Resident #15 was treated with respect, dignity, and care when they failed to ensure Resident #15's linens were clean and the soiled protective boots were removed from the room. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth, psychosocial harm and distrust with staff. Findings Included: Record review of Resident #15's quarterly MDS dated [DATE] revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included: Coronary Artery Disease (poor circulation), heart failure (heart cannot function well), Diabetes Mellitus (high blood sugar), and anemia. Resident #15 was alert 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

“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

$33,117 in federal fines across 2 penalties.

• $14,316 — penalty dated 2025-09-11
• $18,801 — penalty dated 2024-02-28

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

Part of a chain

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

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

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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