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Village Creek Nursing & Rehabilitation

3825 Village Creek Rd, Fort Worth, TX 76119 · For profit - Individual · 100 certified beds · (817) 534-9933 Medicare & Medicaid certified

Call the home — (817) 534-9933 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jul 20241 actual-harm citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$19,009 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2024
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $19,009 in federal fines (most recent 2024-07-11)
  • its payroll-based staffing rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3863 Miller Ave · (817) 536-4942 · Call to confirm hours
Pharmacy
4245 E Berry St · (817) 969-4096 · Call to confirm hours
Grocery
5001 E Berry St · (817) 535-2190 · Call to confirm hours
Park
3765 S Edgewood Ter · Typically dawn to dusk
Place of worship

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

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.9%15.8%15.4%better
Long-stay residents who lose too much weight5.1%3.0%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.0%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.6%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.6%3.3%3.3%better
Long-stay residents whose ability to walk worsened4.9%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.5%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine73.8%98.0%95.3%worse
Long-stay residents with pressure ulcers0.9%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control4.6%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table15.2%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine30.0%88.0%79.4%worse
Short-stay residents rehospitalized after admission26.1%25.7%22.6%worse
Short-stay residents with an outpatient ER visit19.3%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.602.171.67typical
Long-stay outpatient ER visits per 1,000 resident days2.862.061.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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.

10.2%U.S. median 10.7%
Went back to hospital
80.0%U.S. median 56.6%
Met the expected recovery
0.31U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 80.0% 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 25 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 28% 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.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 6.2–15.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge80.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge64.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge64.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.071.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.46
RN hours/ resident / day
0.68
LPN hours/ resident / day
1.73
Aide hours/ resident / day
2.87
Total nurse hours/ resident / day
0.30
RN hoursweekends
51.4%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 87.5 residents a day — about 88% occupied, or roughly 12 beds typically open. It runs fairly full. 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 2.87 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.73 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 2.59 hrs/resident/day on weekends vs 2.98 on weekdays — 13% thinner on weekends. RN hours go from 0.53 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%.

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

Inspection trend

4
deficiencies at the latest standard inspection (2025-08-14)
7
at the previous standard inspection (2024-07-11)

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.

ABCDEFGHIJKL

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.

20 citations, most serious first. The 12 most serious are shown; the remaining 8 are one tap away and print in full.

  • Immediate jeopardy · J2024-07-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (Residents #8) reviewed for abuse. The facility failed to ensure Hospice Aide did not abuse Resident #8. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 05/08/24 and ended on 05/08/24. The facility had corrected the noncompliance before the survey began. This failure could affect the residents at the facility and place them at risk for physical, verbal, and/or psychosocial harm. Findings included: Review of Resident #8's annual MDS assessment dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included cerebral palsy, non-Alzheimer's dementia, seizure disorder, anxiety disorder, contractures of muscles, and need for assistance with personal care. The MDS further reflected the resident was dependent of one staff member for all ADLs including bathing, dressing, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Actual harm · G2024-05-25 · 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 each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure adequate supervision on 05/08/24 when Resident #1 sustained contusions and bruises to left side of face and left eye from an incident/accident. On 05/09/24, Resident #1 was diagnosed with a subdural hematoma ([SDH] occurs when a blood vessel in the space between the skull and the brain [the subdural space] is damaged) and admitted to the hospital. The facility failed to oversee the implementation of resident care policies. LVN A failed to initiate and document investigation of an incident/accident on 05/08/24, per the facility's policy and procedure Fall Management Program, when Resident #1 sustained an fall. These deficient practices of inadequate supervision placed residents at considerable risk of serious injury, harm, and/or impairment.…

    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 before2026-07-02 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 effective pest control program to ensure the facility was free of pests and rodents for 2 of 3 halls (Hall 200 and Hall 400), and 1 of 1 kitchen reviewed for pest control. The facility failed to ensure 200 and 400 halls, and the kitchen were free from pests.This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.Findings included:Hall 400Interview on 07/02/26 at 9:57 AM, Resident # 1 stated he had seen a few flies in his room. He said, most of the time, it was in the evening. He said he waved them off and found them irritating. Observation on 07/02/26 at 10:20 AM revealed a fly flying around and landing in Resident #1's room.Interview on 07/02/26 at 10:26 AM, Resident #2 stated he sometimes saw flies in the dining room, and they bothered him. He said he used someone else's fly swatter when they came near him.Hall 200Observation and interview on…

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

    Environmental Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2025-12-03 · 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, interviews, and record review, 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 1 of 5 residents (Resident #1) reviewed for quality of care.The facility failed to identify and treat swelling on Resident #1's cheekbone following a fall and after Hospice Nurse E and CNA B had identified it on 10/09/25. The failure placed residents at risk for delayed treatment. Findings included:Record review of Resident 1#'s annual MDS assessment, dated 09/13/25, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's diagnoses included metabolic encephalopathy, non-Alzheimer's Dementia (brain disorder caused by damage to nerve cells in the brain), anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), depression (a mood…

    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 before2025-08-14 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 5 residents (Resident #10) reviewed for medication regimens. The facility failed to 's Pharmacy Consultant recommended the facility include anti-psychotic side-effect monitoring for Resident #10's Risperdal and Perphenazine medication orders on 06/18/25 and 07/23/25. This failure could place residents receiving medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition. Findings included: Record review of Resident #10's Quarterly MDS Assessment, dated 07/16/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS score of 13 indicating no cognitive impairment. His active diagnoses included anxiety disorder (a group of mental health conditions characterized by excessive fear, worry, and anxiety that interfere with daily…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-14 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary 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 ensure each resident's drug regimen was free of unnecessary medication for 1 of 5 residents (Resident #10) reviewed for unnecessary medication. The facility did not monitor Resident #10 for side-effects related to the use of the anti-psychotic medications Risperdal and Perphenazine. This failure could place the residents at risk for adverse consequences of medication. Findings included: Record review of Resident #10's Quarterly MDS Assessment, dated 07/16/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS score of 13 indicating no cognitive impairment. His active diagnoses included anxiety disorder (a group of mental health conditions characterized by excessive fear, worry, and anxiety that interfere with daily life), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and schizophrenia (a serious mental health condition that affects how…

    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 · D2025-08-14 · 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 observations, record reviews, and interviews the facility failed to ensure all drugs were stored in locked compartments for 1 of 6 carts (Cart #3) reviewed for medication storage. The facility failed to ensure Cart #3 was secured when not in use.This failure could place residents at risk of gaining access to medications not prescribed to them, leading to allergic reactions or overdoses. Findings included:Observation on 08/13/25 at 2:44 PM revealed Medication Cart #3 was stored at the nurse's station. Observation of the lock revealed it was in the secured position, but a check of the drawers revealed drawer #2 was able to be opened. The other drawers on the cart were locked and were not able to be opened. RN A obtained the keys to the cart, unlocked the cart, and then re-locked the cart; however, drawer #2 on the cart continued to be unlocked. Observation of the contents of drawer #2 revealed it contained the prescription medication cards for the residents of the 200 Hall. The medications included blood pressure medications, anti-viral medications, sleep medications,…

    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 before2025-08-14 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 effective pest control program so that that the facility is free of pests and rodents in 1 of 6 resident rooms (Resident #73) reviewed for pest control. The facility failed to ensure Resident #73's room was free of ants. This failure could place residents at risk of having pests in their rooms and insect bites. Findings included: Record review of Resident #73's Quarterly MDS Assessment, dated 07/26/25, reflected the resident was an [AGE] year-old female initially admitted to the facility on [DATE]. The MDS reflected the resident had moderate cognitive impairment with a BIMS score of 8. The MDS also reflected diagnoses of metabolic encephalopathy (condition where brain dysfunction occurs due to issues with the body's metabolism), adult failure to thrive (a syndrome characterized by weight loss, decreased appetite, poor nutrition, and inactivity, often accompanied by other symptoms like dehydration, depression, impaired immune…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-11 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    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 maintain clinical records that were complete and accurate for two (Resident #18 and Resident #28) of six residents reviewed for clinical records. 1. The facility failed to obtain physician orders for Resident #18 dialysis port site monitoring, vital signs, and documentation of the pre and post dialysis Vitals on the communication form. 2. The facility failed to document when the physician was notified when Resident #28's blood sugar exceeded 250. This failure could place residents at risk for incomplete and inaccurately documented medical record that included their progress treatment, services, and interventions. Findings include: 1. Record review of Resident #18's electronic record reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #18 had diagnoses which included acute kidney failure (when kidneys suddenly become unable to filter waste products from blood) and chronic…

    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 · D2024-07-11 · 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 observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 3 (rooms [ROOM NUMBER]) of 10 rooms reviewed for environment. The facility failed to maintain total visual privacy by allowing the window blinds for room [ROOM NUMBER], 308, and 310 to be missing several slats. This failure placed residents at risk of a lack of privacy, feeling insecure, or uncomfortable in their rooms. Findings included: Observation on 07/09/24 from 8:12 AM-8:40 AM of the facility's Secure Unit revealed the window blinds in Rooms 302, 308 and 310 were broken and missing several blind slats. Interview and observation on 07/10/24 at 2:42 PM with CNA D revealed she had been employed for four weeks. She stated when something needed to be fixed in a resident room, she reported it to the charge nurse. CNA D observed room [ROOM NUMBER] and stated she was aware of the window blinds being broken, but she could not recall how long they had been…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-11 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 to ensure a new resident was not admitted with a mental disorder, unless the state mental health authority determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority prior to admission, that the individual requires the level of services provided by a nursing facility and if the resident requires such level of services, whether the resident requires specialized services for one of six residents (Resident #10) reviewed for PASRR screening. The MDS Coordinator failed to ensure Resident #10's PL1 was accurate with the proper mental illness diagnoses when he was admitted . This failure could place residents at risk of not receiving specialized services. Findings included: Record review of Resident #10's Face sheet, dated 07/11/24, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #10's quarterly MDS assessment,…

    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 · D2024-07-11 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 who was fed by enteral means received appropriate treatment and services to prevent complications for one (Resident #48) of three residents reviewed for feeding tubes. LVN C failed to flush Resident #48's g-tube with 60cc of water before her bolus feeding (feeding method using a syringe to deliver formula through feeding tube) as ordered by the physician. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of G-tube care. Findings included: Record review of Resident #48's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included cerebral palsy, quadriplegia, seizure disorder, and dysphagia (trouble swallowing) and required a feeding tube. The MDS further reflected the resident was dependent of one staff member for all ADLs including bathing, dressing, 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
Show the remaining 8 citations
  • Potential for harm · D2024-07-11 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (Resident #18) reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #18 after return from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care. Findings included: Interview on 07/10/24 at 6:46 AM with Resident #18 revealed she went for dialysis Tuesday, Thursday and Saturday. She stated she got a form that she took to dialysis and brought back to facility. Record review of Resident #18's EHR reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #18 had diagnoses which included acute kidney failure (when kidneys suddenly become unable to filter waste products…

    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 · D2024-07-11 · tag F0914 — isolated
    Provide bedrooms that don't allow residents to see each other when privacy is 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 observation, interview, and record review the facility failed to ensure resident bedrooms were designed or equipped to assure full visual privacy by having ceiling suspended curtains designed to give privacy for one (306 A bed and B Bed) of 4 triple occupied rooms reviewed for privacy. The facility failed to ensure room [ROOM NUMBER] had a privacy curtain between A bed and B bed. This failure placed residents at risk of loss of privacy and dignity and decreased quality of life. Findings included: Observation on 07/09/24 at 8:16 AM of room [ROOM NUMBER] revealed the room had three beds and only two privacy curtains. The room was occupied by three residents. There was no privacy curtain between A bed and B bed. Observation and interview on 07/09/24 at 8:26 AM of Resident #39 in the Day Room sitting watching TV. Resident #39 stated she was doing well. Resident #39 stated she shared a room and her bed was in the middle. Resident #39 was not a good historian and was not able to answer further questions.…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-15 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week for 16 of 34 days (02/26/23, 03/04/23, 03/05/23, 04/02/23, 04/08/23, 04/09/23, 04/15/23, 04/22/23, 04/29/23, 05/20/23, 05/21/23, 05/28/23, 06/03/23, 06/04/23, 06/10/23, and 06/11/23) reviewed for nursing services. The facility failed to have RN coverage for eight consecutive hours for 7 days (Saturdays and Sundays) between 02/26/26 until 06/11/23. This failure could place residents at risk for missed resident nursing assessments, interventions, care, and treatment. Findings included: Record review of timecards for RN F, RN G and RN H for the time-period of 02/26/23 to 06/11/23 revealed there was not eight consecutive hours of RN coverage for 16 out of 34 days (02/26/23, 03/04/23, 03/05/23, 04/02/23, 04/08/23, 04/09/23, 04/15/23, 04/22/23, 04/29/23, 05/20/23, 05/21/23, 05/28/23, 06/03/23, 06/04/23, 06/10/23, and 06/11/23) reviewed for weekend RN coverage on Saturdays and Sundays. Record review of the Employee Timesheets 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-06-15 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 all irregularities identified by the Pharmacist Consultant were reported to the attending physician and acted upon to minimize or prevent adverse consequences to the extent possible for 4 residents (Resident #78, Resident #77, Resident #45 & Resident #33) of 7 resident reviewed for drug regimen reviews, in that: 1. On 03/08/23 the Pharmacist Consultant recommended adding heart rate (pulse) to current hold parameters to Resident #78's order for Coreg (alpha and beta blocker used for hypertension) due to the medication having an effect on heart rate. The physician acknowledged the recommendation; however, the facility failed to ensure that the order was updated with hold parameters for pulse. 2. On 03/08/23 and 05/08/23 the facility's Pharmacist Consultant recommended that Resident #77 have a complete and signed informed consent on file for the use of Seroquel (antipsychotic medication). The physician acknowledged the recommendation; however, 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 · E2023-06-15 · 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, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items and clean dishes were kept away from airborne contaminants and an unsanitary environment. These failures could place all residents, who receive food from the kitchen, at risk for food contamination and food-borne illness. Findings included: Observation of the kitchen on 06/12/23 at 6:30 PM revealed the ceiling just above the food preparation area was splattered with an unknown brown substance, with some spots shiny and sticky-like. The ceiling just above where the pots and pans were stored had an unknown yellowish, hard, and textured substance in multiple spots. In the same area, one vent on the ceiling was observed with rust and fluttering lint. Interview on 06/12/23 at 6:45 PM with [NAME] A revealed all kitchen staff were trained and in-serviced on kitchen sanitation several times per month and as needed. She stated it was 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-15 · 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 on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Resident #24, Resident #83, and Resident#69) of 5 residents reviewed for infection control. The facility failed to ensure MA C disinfected the blood pressure cuff in between blood pressure checks for Residents #24, #83, and #69. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident# 24's quarterly MDS assessment, dated 05/25/23, revealed the resident was [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included elevated blood pressure, muscle weakness, and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Resident #24 had…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-15 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Residents #81) of 18 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #81's care plan accurately reflected being a smoker. This failure placed residents at risk of not having their individual care needs met, which could cause a decline in physical health, psychosocial health, and quality of care. Findings included: Record review of Resident #81's face sheet, dated 06/15/23, revealed the resident was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included heart failure, hypertension (high blood pressure), diabetes mellitus, and renal (kidney) failure. Record review of Resident #81's MDS quarterly assessment, dated 03/17/22, revealed 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 · D2023-06-15 · 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 residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #37) of two residents reviewed for pressure ulcers in that: 1. The facility failed to order wound supplies as per physician orders when Resident #37 was seen on 06/12/23 by the Wound Care Physician. 2. LVN D failed to update physician wound care orders in the MAR when Resident #37 was seen by the Wound Care Physician on 06/12/23. These failures placed residents at risk for deterioration of existing pressure ulcers. Findings included: Review of Resident #37's face sheet revealed Resident #37 was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses senile degeneration of brain and Stage 3 pressure ulcer of sacral region. Review of physician's orders dated 06/12/23 revealed Resident #37'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 · 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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$19,009 in federal fines across 2 penalties.

  • $10,842 — penalty dated 2024-07-11
  • $8,167 — penalty dated 2024-05-25

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 OPCO SKILLED MANAGEMENT — 66 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 →

RatingThis homeChain avg
Overall 3 of 52.3+0.7 vs chain
Health inspection 4 of 52.2+1.8 vs chain
Staffing 1 of 51.7-0.7 vs chain
Quality measures 4 of 54.3-0.3 vs chain
The other 65 homes this chain runs (chain average 2.3★, per CMS)
1 of 5Bluebird Wellness And RehabilitationSaint Louis, MO 1 of 5Brentwood Place ThreeDallas, TX 1 of 5Broadway Nursing & RehabilitationSan Antonio, TX 1 of 5Cameron Nursing CenterCameron, MO 1 of 5Carmel Hills Wellness & RehabilitationIndependence, MO 1 of 5Casa Arena Healthcare LLCAlamogordo, NM 1 of 5Casa Maria HealthcareRoswell, NM 1 of 5Forest Park Nursing & RehabilitationDallas, TX 1 of 5Fort Worth Wellness & RehabilitationFort Worth, TX 1 of 5Glenview Wellness & RehabilitationNorth Richland Hills, TX 1 of 5Highland Pines Nursing HomeLongview, TX 1 of 5Ivy Creek Wellness & RehabilitationWaco, TX 1 of 5Las Cruces Village Nursing & Rehabilitation LLCLas Cruces, NM 1 of 5Magnolia Wellness CenterSaint Louis, MO 1 of 5Maple Grove Wellness & RehabilitationFenton, MO 1 of 5Mineola Gardens Wellness & RehabilitationMineola, TX 1 of 5Pine Grove ManorSaint Louis, MO 1 of 5Rehab Of Kansas City SouthKansas City, MO 1 of 5The Hillcrest Of North DallasDallas, TX 1 of 5West Side Campus Of CareWhite Settlement, TX 1 of 5Willow Ridge Wellness & RehabilitationFort Worth, TX 1 of 5Willowcreek Wellness & RehabilitationFlorissant, MO 2 of 5Arbor Lake Nursing & Rehabilitation, LLCFort Worth, TX 2 of 5Aztec HealthcareAztec, NM 2 of 5Betty Dare Wellness & Rehabilitation LLCAlamogordo, NM 2 of 5Blue Springs Wellness & RehabilitationBlue Springs, MO 2 of 5Cypress Springs Wellness & RehabilitationMount Vernon, TX 2 of 5Fiesta Park Wellness & RehabilitationAlbuquerque, NM 2 of 5Hilltop At Blue River, TheKansas City, MO 2 of 5La Vida Buena HealthcareLas Vegas, NM 2 of 5Los Alamos Wellness & RehabilitationLos Alamos, NM 2 of 5McGregor Wellness & RehabilitationMc Gregor, TX 2 of 5Monarch Springs Wellness & RehabilitationUniversity City, MO 2 of 5Northrise Wellness & RehabilitationLas Cruces, NM 2 of 5Prescott Valley Nursing & RehabilitationPrescott Valley, AZ 2 of 5Prescott Village Nursing & RehabilitationPrescott, AZ 2 of 5Rehabilitation Center Of Independence, TheIndependence, MO 2 of 5San Antonio Wellness & RehabilitationSan Antonio, TX 2 of 5Skyline Nursing CenterDallas, TX 2 of 5Sunny Springs Nursing & RehabSulphur Springs, TX

Showing 40 of 65; lowest-rated first.

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

Owner / managerTypeRoleShareSince
FRIO HOSPITAL DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2024
RUFF, MICHAELIndividualCORPORATE OFFICERsince 01/01/2024
VILLAGE CREEK NURSING & REHABILITATION LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
GARETZ, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
GURWITZ, SOLOMONIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 06/26/2025
HAGINS, ELIZABETHIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/09/2025
KAPLAN, ESTHERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 06/26/2025
KAPLAN, MORDECHAIIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/09/2025
MINDLE, ADAMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/09/2025
UNGER, JEFFREYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 06/26/2025
3825 VILLAGE CREEK ROAD, LLCOrganizationADP OF THE SNFsince 01/01/2024
ALTITUDE REALTY HOLDINGS, LLCOrganizationADP OF THE SNFsince 01/01/2024
CONTINUUM REHAB GROUP LLCOrganizationADP OF THE SNFsince 01/01/2024
GIBRALTAR TRUSTOrganizationADP OF THE SNFsince 01/01/2024
LARCHMONT REALTY, LLCOrganizationADP OF THE SNFsince 01/01/2024
MONTGOMERY SKY TRUSTOrganizationADP OF THE SNFsince 01/01/2024
OPCO CA SKILLED MGMT INC.OrganizationADP OF THE SNFsince 01/01/2024
OPCO TEXAS SKILLED MGMT LLCOrganizationADP OF THE SNFsince 01/01/2024
LEWIS, ADOLPHUSIndividualADP OF THE SNFsince 01/01/1989
OSBORNE, GLORIAIndividualADP OF THE SNFsince 01/01/2024

10 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.

$2.3M
Net patient revenuemost recent cost report
+1.5%
Operating marginrevenue minus expenses
$126K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 77%Medicare 4%Other / private 18%

About 77% 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. This home reported $126K paid to related parties (affiliated landlords or management companies) in its most recent 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

$231per resident / day
operating cost
$7,032per month
≈ monthly operating cost
$235per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675977. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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