Green Valley Healthcare and 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.

49.9% 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 88 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 50.0% 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 0.38 therapist hours per resident per day in 2026Q1 — more than 64% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 124 beds and averages 88.0 residents a day — about 71% occupied, or roughly 36 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 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 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 3.26 hrs/resident/day on weekends vs 3.89 on weekdays — 16% thinner on weekends. RN hours go from 0.59 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 28% is below 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.

35 citations, most serious first. The 16 most serious are shown; the remaining 19 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-09-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 9 residents reviewed for accidents. The facility failed to ensure Resident #1, who required a mechanical lift transfer, was free of an accident hazard on 08/12/25 when she was transferred by CNA B without a mechanical lift and sustained a significant injury. Resident #1 was transported to the local hospital and diagnosed with a right humerus fracture. An Immediate Jeopardy (IJ) was identified on 09/04/25 at 04:00 PM and an IJ Template was provided to the DON at 04:41PM. While the IJ was removed on 09/05/25, the facility remained out of compliance at a scope of isolated with the severity level of potential for more than minimal harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for accidents that could lead to a…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-09-04 · 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 observation, interviews and record reviews, the facility failed to immediately consult with the resident's physician and notify the resident representative when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of eight residents reviewed for notify of changes. -The facility failed to notify Resident #1's physician and responsible party when the resident showed signs of an altered mental status for at least 22 hours and was later diagnosed with severe sepsis at the local hospital. On 09/03/24, an Immediate Jeopardy was identified. The IJ template was provided to the facility on [DATE] at 5:45 PM. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-09-04 · 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 review, the facility failed to identify and provide needed care or services that resulted in an actual or potential decline in one or more resident's physical, mental, and psychosocial well-being for one (Resident #1) of four residents reviewed for quality of care. The facility failed to identify, monitor, assess, evaluate, and document Resident #1's changes in the bowel regimen. The facility failed to provide Resident #1 as needed (PRN) medication for constipation. The facility failed to evaluate Resident #1's bowel sounds as indicated and report significant abnormalities to the provider per the care plan intervention initiated, 07/12/2024. The facility failed to notify the provider of Resident #1's last known bowel movement on 08/08/24. The facility failed to notify the provider about Resident #1's STAT lab results received on 08/26/24 at 3:21 PM . On 08/27/24, Resident #1 was admitted to the hospital for altered mental status (AMS). Resident #1 was admitted , diagnosed, 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-09-04 · tag F0773 — isolated
  Provide or obtain laboratory tests/services 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 physician of laboratory results in accordance with facility policy and procedures for notification for one (Resident #1) of four residents reviewed for laboratory services. The facility failed to notify the provider about Resident #1's STAT lab results received on 08/26/24 at 3:21 PM. On 08/27/24, Resident #1 was admitted to the hospital for altered mental status (AMS). Resident #1 was admitted , diagnosed, and treated for severe sepsis, chronic constipation, and fecal impaction. On 09/03/24, an Immediate Jeopardy was identified. The IJ template was provided to the facility on [DATE] at 5:45 PM. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-10-31 · 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; and notify, the resident representative(s) when there was a deterioration in resident's health condition for one (Resident #3) of three residents reviewed for skin conditions. The WCN failed to notify Resident #3's physician and responsible party of the deterioration of a pressure ulcer on the right heel. On 9/28/2023 the wound measured 2cm x 1.5cm and remained unchanged until 10/19/2023 when the wound measured 6x6 cm. The WCN failed to notify Resident #3's physician and responsible party of the presence of a new pressure injury along the inner edge of the right foot, extending from near the heel to the bunion region of the big toe. Resident #3 was discharged to the emergency room on [DATE] because of elevated temperature and weakness, then admitted to the hospital with the diagnosis of sepsis from pneumonia and right foot wound. An immediate Jeopardy (IJ) situation was identified on 10/30/2023. While…

  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 before2023-10-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #3) of 3 residents reviewed for pressure ulcers. The facility failed to ensure Resident #3 did not experience a worsening of an existing pressure ulcer and did not develop a new pressure ulcer. The pressure ulcer on the rt heel increased in size and a new pressure injury (inner edge of the right foot) was identified on 10/12/2023. The facility failed to ensure there was documentation in the clinical record in the form of the wound weekly observation tool documenting the occurrence of the new wound on the inner edge of the right foot. The facility failed to ensure Resident #3 was provided with individual treatment orders for the pressure injury that was identified on 10/12/2023. Resident #3 was discharged 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-06-17 · 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 observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for three of ten residents (Resident #14, Resident#57 and Resident #74) reviewed for accident hazard. The facility failed to ensure a pair of scissors was not on Resident #14's bed on 06/15/2026. The facility failed to ensure a pair of scissors was not on Resident #57's bed on 06/15/2026. The facility failed to ensure a fingernail clipper was not on Resident #74's bedside table on 06/15/2026. These failures could prevent the residents from having an environment that was free from accidents and potential injury. Findings included: 1. Record review of Resident #14's Face Sheet, dated 06/17/2026, reflected a [AGE] year-old female, admitted on [DATE]. The resident was diagnosed with Type 2 Diabetes (a chronic condition where the body either resists insulin or do not produce enough of it, leading to high blood sugar), Psychotic disorder (severe mental illnesses…

  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 no plan of correction
• Potential for harm · Dcited before2026-06-17 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature control for 3 residents (Resident #22, Resident #75 and Resident #105) medication on 1 of 3 medication carts (100 Hall nurse cart) reviewed for pharmacy services.1. The facility failed to ensure proper disposal of Resident #22's Tramadol 50mg tab when the blister pack was damaged. 2. The facility failed to ensure proper disposal of Resident #75's Acetaminophen-Codeine #3 tab when the blister pack was damaged. 3. The facility failed to ensure proper disposal of Resident #105's Lorazepam 0.5mg tab when the blister pack was damaged. 4. The facility failed to ensure CMA A ensured that Resident #11 swallowed her medication before leaving the resident's room. These failures could place residents at risk for compromised medication efficacy, unsafe administration, and increased harm to residents.Findings included: 1. Record review of Resident #22's Comprehensive 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.

  Pharmacy Service Deficiencies · Deficient, Provider has no plan of correction
• Potential for harm · E2026-05-04 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were free from significant medication errors for 1 (Resident #1) of 3 residents reviewed for medication errors in that:The facility failed to administer Resident #1's Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG as ordered by the physician on 04/27/26, 04/28/26, 04/29/26.This failure could place residents at risk of medical complications and a decrease in therapeutic dosages of their medications as ordered by the physician.Findings included:Review of Resident #1's MDS assessment dated [DATE] revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her BIMS was a 15 indicating she was cognitively intact. Her diagnoses included: HTN.Record review of Resident #1's care plan with a competition date of 04/22/26 reflected: Focus: The resident has hypertension.Date Initiated: 04/06/2026.Goal: The resident will remain free from s/sx of hypertension through the review date.Interventions: Give anti…

  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 · D2026-05-04 · tag F0636 — isolated
  Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
  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 comprehensive assessment within 14 calendar days after admission as required for 1 (Resident #3) of 3 resident records reviewed.The facility failed to ensure Resident#1's Admission/Comprehensive MDS assessment was completed within 14 days following her admission to the facility.This failure could result in newly admitted residents not receiving the proper care required to attain or maintain the highest practicable physical, mental and psychosocial well-being. Findings included:Review of Resident #1's MDS assessment dated [DATE] revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her BIMS was a 15 indicating she was cognitively intact. Her diagnoses included: HTN, DVT, GERD .Record review of Resident #1's MDS Summary screen in the Electronic Health Record on 05/04/26 revealed the resident's MDS had an ARD date of 04/10/26 and was completed on 04/21/26 (11 days after the ARD date). In an interview on 05/04/26 at…

  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 before2026-05-04 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for one (treatment cart #1) of 4 reviewed for storage of medications.The facility failed to ensure treatment cart #1 was locked while unattended on 05/04/26This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included:An observation on 05/04/26 at 8:50 AM revealed treatment cart #1 was unlocked and unattended with no staff within eyesight of the medication cart. All drawers could be opened, and medication and supplies (needles, gauze, ointments, etc. ) could be easily accessed. In an interview on 05/04/26 at 8:54 AM, with LVN B stated treatment cart #1 belonged to the wound care nurse who was not at work. In an observation and interview on 05/04/26 at 8:55 AM, ADON C locked treatment cart #1. ADON C stated that her expectation was the treatment cart was locked when not in use. She stated it was the responsibility of the nurse who used the cart last to lock the…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-17 · tag F0583 — failed to protect personal privacy — pattern
  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 treat each resident with respect, dignity, and care in a manner and environment that promoted maintenance or enhancement of his or her quality of life for three (Resident #4, Resident #61, and Resident #186) of residents reviewed for Privacy and Confidentiality. 1. The facility failed to ensure Resident #186's medical information was not left on top of a documentation cart on 04/15/2025. 2. The facility failed to ensure MA H did not leave Resident #61s' medical information on top of the medication cart unattended on 04/15/2025. 3. The facility failed to ensure Resident #4's medical information was not left on top of a cart on 04/15/2025. 4. The facility failed to ensure MA I did not leave Resident #4's medical information on top of the medication cart unattended on 04/17/2025. These failures could place the residents at risk of their medical information being exposed to unauthorized individuals. Findings included: 1. Record review of…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-17 · 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 residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 13 of 16 resident rooms on the 100 hall (Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13), and the air condition unit on the 100 hall, reviewed for environment. 1. The facility failed to ensure resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 were thoroughly cleaned and sanitized. 2. The facility failed to ensure the air condition unit on the 100 hall was thoroughly cleaned and sanitized. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings include: An observation on 04/15/25 at 11:02 AM of resident room [ROOM NUMBER] reflected the air vent in the room had thick black dirt between the vents. 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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-04-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  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 five (Resident #3, #4, #80, #187, and #188) of twenty residents reviewed for Respiratory Care. 1. The facility failed to ensure Resident #3's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored when not in use on 04/15/2025. 2. The facility failed to ensure Resident #4's humidifier bottle (a medical device designed to increase the moisture level in supplemental oxygen) had water in it on 04/15/2025. 3. The facility failed to ensure an Oxygen in Use sign was outside Resident #80's room on 04/15/2025. 4. The facility failed to ensure Resident #188's nasal cannula was properly stored when not in use on 04/15/2025. 5. The facility failed to ensure Resident #187's nasal cannula…

  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 observation, interview, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure the ice machine and ice scoop holder in the facility kitchen was thoroughly cleaned. 2. The facility failed to ensure kitchen cooking equipment was cleaned. 3. The facility failed to place a cover on top of the tea dispenser to avoid air borne contaminants. 4. The facility failed to ensure cooking equipment in the dining area was clean and sanitized. 5. The facility failed to label and date food stored in the refrigerator once it was opened and used. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations on 04/15/25 from 9:08 AM to 9:22 AM in the facility's only kitchen revealed: The ice machine, located in the kitchen had brown stains on the inside of the door and along the opening of the machine. The ice scoop holder,…

  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 · Ecited before2025-04-17 · 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 observation, interview, and record review the facility failed to establish and 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 four (Resident #9, Resident #41, Resident #81, and Resident #187) of ten residents reviewed for Infection Control. 1. The facility failed to ensure CNA F changed her gloves and performed hand hygiene before, after, and while providing incontinent care to Resident #41 on 04/15/2025. 2. The facility failed to ensure LVN C wore a gown while administering Resident # 9's medications via g-tube 04/16/2025. 3. The facility failed to ensure LVN C wore a gown while administering Resident #81's medication via g-tube 04/16/2025. 4. The facility failed to ensure WCN J wore a gown while performing Resident #187's wound care and changed her gloves after touching the outside edge of the resident's foot on 04/16/2025. These failures…

  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

$96,925 in federal fines across 3 penalties.

• $17,345 — penalty dated 2025-09-05
• $24,093 — penalty dated 2024-09-04
• $55,487 — penalty dated 2023-10-31

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 NEXION HEALTH — 51 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 10 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

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

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.

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