Willow Ridge Wellness & Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 36% 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 265 beds and averages 92.0 residents a day — about 35% occupied, or roughly 173 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.05 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.72 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 2.65 hrs/resident/day on weekends vs 3.21 on weekdays — 17% thinner on weekends. RN hours go from 0.31 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

Inspection trend

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

Inspection deficiencies

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

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

38 citations, most serious first. The 24 most serious are shown; the remaining 14 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-08-15 · 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 interview and record review, the facility failed to ensure that each resident received adequate supervision to provide an environment that was free of accident hazards for one (Resident #1) of five residents reviewed for accidents. -The facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents when Resident #1 cut his wrist with a sharp object, had to be hospitalized with a 4cm laceration to his wrist and was admitted for a psychiatric evaluation. Resident #1 had diagnoses of mental illness and IDD, a history of having razors in his possession, and a history of aggressive behaviors. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 8/12/25 and ended on 8/14/25. The facility had corrected the non-compliance before the state's investigation began. This failure could place residents at risk for accidents that could lead to serious injury, harm, or…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2025-05-29 · 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 observations, interviews and record reviews, the facility failed to ensure that residents were free from abuse for two (Resident #1 and #2) of six residents reviewed for abuse and neglect. The facility failed to protect Resident #1 and #2 from abuse on 05/22/25 when both residents got into a physical altercation and fell to the ground. As a result, Resident #1 sustained a superior endplate fracture suspected at T4 vertebral body (top part of the T4 spinal bone is cracked/broken) and right periorbital hematoma (black right eye). An IJ was identified on 05/28/25. The IJ template was provided to the facility on [DATE] at 1:30 PM. While the IJ was removed on 05/29/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure placed residents at risk for abuse, neglect, and emotional and psychological harm. Findings…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-05-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 residents (Resident #1 and #2) of 6 residents reviewed for adequate supervision. The facility failed to provide adequate supervision to Resident #1 and Resident #2 when both residents got into a physical altercation and fell to the ground. As a result, Resident #1 sustained a superior endplate fracture suspected at T4 vertebral body (top part of the T4 spinal bone is cracked/broken) and right periorbital hematoma (black right eye). An IJ was identified on 05/28/25. The IJ template was provided to the facility on [DATE] at 5:05pm. While the IJ was removed on 05/29/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk…

  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 before2024-04-27 · 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, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify consistent with his or her authority, the resident representative when there was a change in the resident's physical, mental, or psychosocial status for 1 resident (Resident #1) of 9 residents reviewed for notification of change of condition. The facility failed to ensure the MD and/or the Wound Care Doctor were consulted for direction on wound care orders for Resident #1 upon readmission to the facility on [DATE] with two small open wounds on the right and left buttock. The facility failed to ensure the MD and/or the Wound Care Doctor were consulted for direction on wound care orders on 04/11/2024 when a new wound developed on Resident #1's coccyx. Resident #1 was not seen by the Wound Care Doctor until 04/22/24 and was sent out to hospital with an unstageable wound on her sacrum, resulting in surgery to debride the wound. An Immediate Jeopardy (IJ) was…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-04-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents receive care, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 9 residents reviewed for pressure ulcers. The facility failed to ensure the MD and/or the Wound Care Doctor were consulted for direction on wound care orders for Resident #1 upon readmission to the facility on [DATE] with two small open wounds on the right and left buttock. The facility failed to ensure the MD and/or the Wound Care Doctor were consulted for direction on wound care orders on 04/11/2024 when a new wound developed on Resident #1's coccyx. Resident #1 was not seen by the Wound Care Doctor until 04/22/24 and was sent out to hospital with an unstageable wound on her sacrum, resulting in surgery to debride the wound. An Immediate Jeopardy (IJ) was identified on 04/26/2024. While the IJ was removed on 04/27/2024 at 12:30 PM, the facility…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-10-14 · 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 observation, interview, and record review, the facility failed to consult with the physician when the resident experienced a change in condition for one (Resident #1) of nine residents reviewed for a change of condition: -The facility failed to notify the physician of a change in condition for Resident #1 after he exhibited unusual behaviors, became combative, and refused administration of insulin, which resulted in the resident having a fall and sustaining critical injuries. An Immediate Jeopardy was identified on 10/13/23. While the Immediate Jeopardy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment and worsening in condition. Findings included: Record review of Resident #1's face sheet, dated 10/12/23, reflected 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
• Immediate jeopardy · Jcited before2023-10-14 · 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 the resident's right to be free from neglect for one (Resident #1) of nine residents reviewed for neglect. -The facility staff were aware of the goods and services Resident #1 required per his care plan and orders, and failed to provide them (insulin), without additional intervention by notifying the physician, and as a result the resident fell and sustained critical injuries. An Immediate Jeopardy was identified on 10/13/23. While the Immediate Jeopardy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment and worsening in condition. Findings included: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-10-14 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent the neglect of residents for one resident (Resident #1) of nine residents reviewed for neglect. -The facility failed to implement the facility's written policies and procedures to prohibit and prevent neglect of Resident #1 by not providing him goods and services (insulin), without additional intervention by notifying the physician, and as a result the resident fell and sustained critical injuries. An Immediate Jeopardy was identified on 10/13/23. While the Immediate Jeopardy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment and worsening in condition. Findings included: 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-10-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one resident (Resident #1) of nine residents reviewed for change in physical, mental, or psychosocial status. -The facility failed to notify the physician of a change in condition for Resident #1 after he exhibited unusual behaviors, became combative, and refused administration of insulin, which resulted in the resident having a fall and sustaining critical injuries. An Immediate Jeopardy was identified on 10/13/23. While the Immediate Jeopardy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment 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 · Jcited before2023-05-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (Resident #38) of 17 residents reviewed for labs and diagnostics. The facility failed to retrieve results of an x-ray order of Resident #38's right arm in a timely manner after he was noted to be grimacing in pain and unable to move his right arm, which resulted in delayed treatment of a fractured clavicle for approximately 24 hours. An Immediate Jeopardy was identified on 05/11/23. While the Immediate Jeopardy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. These failures could affect residents by placing them at risk for untreated illnesses, and delays in necessary care 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 · J2023-05-12 · tag F0777 — isolated
  Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to promptly notify the ordering physician of results that fell outside of clinical reference ranges in accordance with facility policies and procedures for one (Resident #38) of four residents reviewed diagnostic services. The facility failed to retrieve results of an x-ray order of Resident #38's right arm in a timely manner after he was noted to be grimacing in pain and unable to move his right arm, which resulted in delayed treatment of a fractured clavicle for approximately 24 hours. An Immediate Jeopardy was identified on 05/11/23. While the Immediate Jeopardy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. These failures could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in…

  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
• Actual harm · H2025-05-08 · tag F0602 — failed to protect residents from theft of their belongings — pattern
  Protect each resident from the wrongful use of the resident's belongings or money.
  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 the right to be free from Misappropriation of Resident Property for 1 of 5 residents (Resident #1), reviewed for drug diversion. The facility failed to prevent the misappropriation of over 150 tablets of Norco (hydrocodone and acetaminophen an opioid which is a Schedule II controlled Substance), and 1 bottle of morphine (30 mL), by allowing the ADON (AP) to remove the medication from the nurses' cart, without authorization, for personal gain and never recovering the medication. Resident #1 experienced pain for two-three days at a level of 7-8, after his toe amputation, when his pain would have been relieved with Norco. This noncompliance was identified as a PNC. The noncompliance began on 4-14-2024 and ended on 4-28-2025. This failure could place residents at risk of misappropriation if medication resulting in unrelieved pain and substandard quality of life. Findings Included: Record review of Resident #1's Face Sheet dated 5-8-2024 revealed 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2025-05-08 · 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 interview, and record review, the facility failed to ensure residents were free from abuse for one of five residents (Resident #2) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #2 was free from staff to resident abuse when CMA A slapped a glass of water out of Resident #2's hand on 4-23-2025, causing her to cry experiencing psychosocial harm. This noncompliance was identified as a PNC. The noncompliance began on 4-23-2024 and ended on 4-30-2025. This failure could place residents at risk for decreased quality of life, decreased self-esteem, and mental anguish. Findings Included: Record review of Resident #2's Face Sheet dated 5-8-2025 revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of Dementia with other behavioral disturbance (a decline in mental ability severe enough to interfere with daily life) and secondary diagnoses of Parkinsonism (a broad term encompassing various conditions that share similar movement…

  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 · Gcited before2025-02-28 · 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, record review, and interviews, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #1) reviewed for wound care services. The facility failed to enter the wound care physician's orders given on 2-10-2025 until 2-13-2025, did not put the physician's orders that were given on 2-17-2025 until 2-20-2025, according to the TAR. Treatment for the wound did not start until the dates the orders entered, according to the TAR. The facility failed to obtain orders for wound care when Resident #1 admitted to the facility on [DATE], from the hospital, with a stage II pressure injury to his buttocks. Wound care orders were not obtained until 2-10-2025 and not entered into the EHR System until 2-13-2025. Wound care orders were changed on 2-17-2025 and not entered into the EHR System until 2-20-2025. According to…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-31 · 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

  Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (adjacent hallway to the 300 Hall) out of 2 hallways reviewed for accidents and hazards.1.The facility failed to ensure that 3 of 3 mechanical lifts on the hallway adjacent to the 300 Hall were locked and secured when not in use.This failure could place residents, visitors and staff at risk of falls and/or injuries. Findings Included:Observation of the hallway adjacent to the 300 Hall on 03/29/26 at 4:36 PM revealed 3 unlocked and unsecured mechanical lifts parked on the hallway adjacent to the 300 Hall. Observation of the hallway adjacent to the 300 Hall on 03/29/26 at 7:01 PM revealed 3 unlocked and unsecured mechanical lifts parked on the hallway adjacent to the 300 Hall. Observation of the hallway adjacent to the 300 Hall on 03/30/26 at 3:50 PM revealed 3 unlocked and unsecured mechanical lifts parked on the hallway adjacent to the 300 Hall.Observation of the hallway adjacent to the 300 Hall on 03/30/26 at 5:26 PM…

  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 before2026-01-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely for one (Resident #1) of seven residents reviewed for dignity. 1. Staff failed to ensure Resident # 1 was not laying directly on the sealed protective plastic packaging with her bare skin touching the plastic on 01/29/26. The failure could place residents at risk for skin irritation, poor sleep quality, and suffocation hazards.Findings included: Resident #1Record review of Resident #1's admission record, dated 01/29/26, reflected an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included sequelae of cerebral infarction (aftereffects of stroke such as memory loss, paralysis, depression and chronic pain, that has impacted daily life and independence), glaucoma in both eye (this is an eye disease that causes vision…

  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 · Fcited before2025-07-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen observed for food safety. The facility failed to ensure the stand-by refrigerator free of personal food itemsThe facility failed to ensure the walk-in refrigerator food items were dated, labeled and securely stored.The facility failed to ensure the walk-in freezer food items were dated, labeled and securely stored.The facility failed to ensure the dry storage food items were dated, labeled and securely stored.The facility failed to ensure that canned good food items were free of dents.The facility failed to ensure that dishwashing protocol was followed.The facility failed to ensure that prepared foods were held correctly and maintained safe temperatures. These failures could place residents at risk for foodborne illnesses.Findings included: Observation on 07/22/2025 at 09:03AM of the walk-in refrigerator revealed the following:Deli sandwiches dated 7/21/25 in an unsealed…

  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 before2025-07-24 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record review, the facility failed to provide a clean and homelike environment for three of five residential halls (Hall 200, Hall 300, and Hall 400) reviewed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure six air duct registers were free of small black spots, rust, paint chipping and securely fit into ceiling tiles. These failures could place residents at risk for decline in health and decreased quality of life due to living in unclean and non-homelike environment.Findings included: Observation on 07/22/2025 at 10:26AM in Hall 200 revealed: S One ceiling air duct register covered with small black spots. S One ceiling air duct register, with rust and peeled paint chips. Observation on 07/24/2025 at 11:59AM in Hall 300 revealed: S Two ceiling air duct registers covered with small black spots and rust S One ceiling air duct register covered with small black spots Observation on 07/24/2025 at 12:07PM in Hall 400 revealed: S One ceiling air duct register with small black spots in a white ceiling tile with…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-24 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interview, and record review, the facility failed to ensure residents have a right to a dignified existence for one resident (unidentified resident) of one resident reviewed for resident rights. The facility failed to ensure one staff member was not on the phone while assisting one resident with their meal. This failure could cause residents to have a negative psychosocial outcome.Findings included: Observation on 07/23/2025 at 12:23PM revealed LVN F was on the phone while assisting a resident (unidentified) during lunch. During an interview on 07/24/2025 at 12:29PM LVN F revealed he was on the phone with the doctor while assisting a resident with their meal. He stated it was not okay to be on the phone while assisting residents with their meals. He explained it drew attention away from the resident, they could pick up something they should not put in their mouth, and its disrespectful. He stated he would not have liked it (if he was in the resident's position) and would want the utmost respect. During an interview on 07/24/2025 at 02:03PM with DON revealed…

  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 · D2025-07-24 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable well-being for one resident (Resident #54) of seven residents reviewed for care plans. The facility failed to complete care plans addressing Resident #54's behavior of picking and scratching at wounds on her arm, or her skin condition. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs.Findings included: Review of Resident #54's face sheet, dated 07/22/25, reflected she was an [AGE] year-old female, admitted on [DATE], with diagnoses which atopic neurodermatitis (a type of eczema which causes intense itching, leading to thick, leathery patches of skin), stroke affecting her left side, and anxiety disorder. Review of Resident #54's admission MDS assessment, dated 06/17/25,…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-24 · 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 the resident environment remained free of accident hazards as is possible for 1 (Resident #42) of 15 residents and 6 residents on the south suits hall reviewed for accidents and hazards in that; 1. Resident #42 had an electrical extension cord and a multiple receptacle plug-in adaptor in his room.2. The facility failed to secure the exit door at the end of south suites hall. This failure could place residents at risk of harm due to wondering or elopement.1. Record review of Resident #42's face sheet, dated 07/22/25, reflected he was a [AGE] year-old man, admitted to the facility on [DATE], with diagnoses of stroke, depression, uncontrolled blood sugar, hemiplegia and hemiparesis following cerebral infraction affecting the left non-dominant side (this is the paralysis and numbness after a stroke on the left side), limited mobility, and age related nuclear cataract in both eyes ( this is the clouding and yellowing of the lens in…

  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 · D2025-06-09 · tag F0842 — failed to keep accurate, complete medical records — isolated
  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 observations and interviewsm the facility failed to maintain medical records on each resident that are accurate for 1 of 5 residents (Resident #1) reviewed for resident records. CNA A failed to accurately document in Resident #1's EHR on 06/06/25 when she documented her care using CNA B's log-in credentials. This failure could lead to incorrect documentation of resident care. Findings included: Record review of Resident #1's undated admission Record reflected the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Alzheimer's, dementia, and high blood pressure. Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 3 indicating he had severe cognitive impairment. His Functional Status assessment indicated he was dependent on staff for all of his ADLs. Record review of Resident #1's care plan, dated 05/30/25, reflected he had an ADL self-care deficit, and impaired cognition being non-verbal. Record review of Resident #1's…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-28 · 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 notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status and/or a need to alter treatment significantly for 1 of 2 residents (Resident #2) reviewed for resident rights. The facility failed to notify Resident #2's representative and/or family, on 5-3-2025, as appropriate of a significant change in Resident #2's mental status. This failure could prevent their representative's authority from being notified or exercised preventing them from receiving competent choices. Findings included: Record review of Resident #2's Face Sheet dated 2-28-2025 revealed an [AGE] year-old female with an initial admittance date of 5-14-2019. Resident #2's primary diagnosis was dementia without psychotic disturbance (cognitive decline characteristic of the condition, but does not exhibit symptoms of psychosis, such as hallucinations or delusions) with…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-28 · tag F0635 — isolated
  Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
  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 have physician orders for the resident's immediate care at the time a resident was admitted for 1 of 1 (Resident #1) resident reviewed for physician orders. The facility failed to obtain physician orders for immediate care when Resident #1 admitted to the facility on [DATE] with a pressure wound to receive orders for treatment. This failure could place residents at risk for delayed treatment causing a decline in health by not receiving treatment until two weeks later. Findings included: Review of Resident #1's Face Sheet dated 02/05/25 reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses in part included hypertension (elevated blood pressure), neurogenic bladder (lack of bladder control due to brain, spinal cord, or never problem), quadriplegia (paralysis affecting all limbs and body from the neck down), diabetes (disease affecting the body's use of sugar), obesity (complex disease involving having…

  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

“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

$321,244 in federal fines across 7 penalties.

• $17,594 — penalty dated 2025-08-15
• $62,192 — penalty dated 2025-05-29
• $12,637 — penalty dated 2025-05-08
• $14,742 — penalty dated 2025-05-08
• $12,425 — penalty dated 2025-02-28
• $187,136 — penalty dated 2024-04-27
• $14,518 — penalty dated 2023-10-14

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

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 →

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

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

Follow the money — this home’s finances

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

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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