Legend Oaks Healthcare And Rehabilitation Center G

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.

48.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 87 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 61.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 36 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 1.16 therapist hours per resident per day in 2026Q1 — more than 98% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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 100 beds and averages 74.9 residents a day — about 75% occupied, or roughly 25 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.41 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 2.58 hrs/resident/day on weekends vs 3.32 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.45 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

39 citations, most serious first. The 17 most serious are shown; the remaining 22 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-10-23 · 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 right to be free from abuse was provided for 1 of 11 residents reviewed for abuse. (Resident #1) The facility failed protect Resident #1 from abuse when RN A recorded him on 07/26/24 with her personal cellphone while undressed from the waist down. RN A was laughing. RN A showed and sent the video to other staff. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/26/24 and ended on 08/30/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for emotional and mental abuse. Findings included: Record review of a face sheet dated 10/22/24 revealed Resident #1 was an [AGE] year-old male and admitted on [DATE] with diagnoses including dementia, depression, and anxiety. Record review of a quarterly MDS dated [DATE] revealed Resident #1 was understood and usually understood others. The MDS revealed a BIMS score of 7, indicating severe cognitive…

  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
• Immediate jeopardy · Jcited before2024-10-23 · 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 implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents for 1 of 11 residents (Resident #1) reviewed for abuse and neglect. The facility failed to prevent Resident #1 from being abused when on 07/26/2024 RN A entered his room and filmed him with her cellphone. Resident #1 was naked from the waist down. RN A shared the video with other staff. The facility failed to protect Resident #1 from potential further abuse after the allegation. RN A was allowed to work from the date of the incident until she was suspended on 08/22/24. The facility staff (RN B, LVN C, CNA D, LVN E, the Staffing Coordinator, the Transport Aide, PTA L) failed to report abuse immediately to the Abuse Coordinator after they had viewed or became aware of the video. Facility Administrator G failed to investigate and to report an allegation of abuse to the state agency after he became aware of the video…

  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
• Immediate jeopardy · Jcited before2024-10-23 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment are reported immediately or not later than 2 hours for 1 of 11 residents reviewed for abuse and neglect. (Resident #1) The facility staff (RN B, LVN C, CNA D, LVN E, the Staffing Coordinator, the Transport Aide, PTA L) failed to report abuse immediately to the Abuse Coordinator after they had viewed or became aware of video taken by RN A of Resident #1 naked from the waist down. Facility Administrator G failed to investigate and to report an allegation of abuse to the state agency after he became aware of the video on 07/31/24. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/26/24 and ended on 08/30/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for ongoing abuse and neglect. Findings included: Record review of a face sheet dated 10/22/24 revealed Resident #1…

  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
• Immediate jeopardy · J2024-10-23 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  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 an allegation of abuse was thoroughly investigated for 1 of 11 residents reviewed for abuse. (Resident #1) The facility Administrator, Administrator G, failed to investigate an incident where RN A videoed Resident #1 in his room naked from the waist down. RN A shared the video with other staff. The facility failed to protect Resident #1 from potential further abuse after the allegation. RN A was allowed to work from the date of the incident until she was suspended on 08/22/24. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/26/24 and ended on 08/30/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for further abuse, physical or psychological harm or injury. Findings included: Record review of a face sheet dated 10/22/24 revealed Resident #1 was an [AGE] year-old male and admitted on [DATE] with diagnoses including dementia,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2023-09-13 · 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 the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for two of two residents (Resident #1 and #2) reviewed for accidents and hazards in that: 1. The facility failed to update Resident #1's elopement evaluation after he exhibited exit seeking behavior, and Resident #1 was able to elope from the facility without staff's knowledge due to an exit door failing to activate and Resident #1 was found on the roadway by police 2. The facility failed to ensure coffee was served at a safe temperature for Resident #2. Resident #2 received second degree burns to the left arm and abdomen after hot coffee was spilled on her. Resident #2 was not thoroughly assessed for burns after the coffee was spilled and treatment was not provided to the abdominal burn until 2 days after the incident occurred 3. The facility failed to have a policy to ensure coffee…

  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
• Actual harm · G2024-06-19 · 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 ensure an effective pest control program so the facility was free of pests for 1 of 3 residents reviewed for pest control. (Resident #2) The facility had an outbreak of flies during the week of 5/23/24 through 6/5/24. On 6/1/24 a Resident #2 was noted with maggots in his wounds on his foot. This failure could cause the facility to become infested with pests. Findings included: Record review of Resident #2's Face Sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were non pressure chronic ulcer of the right foot limited to the skin dated 4/16/22. Hemiplegia( paralysis on one side of the body)followed by a stroke muscle weakness, foot drop of the right foot, and mild cognitive impairment. Record review of Resident #2's Quarterly MDS dated [DATE] indicated intact cognitive status with a BIMs of 14. Resident #2's functional status was partial to maximum assistance with ADLs and sit up help…

  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
• Actual harm · H2024-02-22 · tag F0603 — failed to not confine residents against their will — pattern
  Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
  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 did not ensure residents had the right to be free from involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 1 of 4 (Resident #1) residents reviewed for involuntary seclusion. The facility failed to follow their policy for residents refusing the test for COVID-19 resulting in Resident #1 being placed in isolation from 7/18/23 through 8/18/23 (32 days), 10/3/23 through 10/16/23 (13 days), and 11/6/23 through 11/11/23 (6 days). This failure could place residents at risk for increased depression and emotional and psychological harm. Findings included: Record review of the face sheet dated 2/22/24 indicated Resident #1 admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), hemiparesis (partial weakness to one side) and hemiplegia (paralysis to one side) following cerebral infarction affecting the left side, dementia, muscle weakness, and lack of coordination. Record…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-23 · 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 interview, and record review, the facility did not ensure treatment and services was provided, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 1 of 3 residents reviewed for quality of care. (Resident #1)The facility failed to implement treatment orders for Resident #1's right heel as ordered by Wound Care Specialist from 5/11/2026-5/18/2026.This failure could place residents at risk for developing avoidable pressure injuries and the worsening of existing pressure injuries.Findings included:Record review of Resident #1's face sheet, dated 5/23/2026, indicated Resident #1 was a [AGE] year-old female, admitted [DATE], diagnoses included intracapsular fracture of right femur (occurs within the joint capsule of the hip, most often involving the femoral head or neck), Hyperlipidemia (a condition characterized by elevated levels of cholesterol in the blood), Alzheimer's (most common cause of dementia, a condition involving significant memory…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-04-15 · tag F0572 — pattern
  Give residents a notice of rights, rules, services and charges.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record review the facility to ensure residents were informed orally of their rights for 8 of 8 confidential residents reviewed for resident rights. The facility failed to ensure residents were provided ongoing communication of their rights during their stay at the facility. This failure could place residents at risk for a decreased quality of life and awareness and execution of their rights. The findings included: A record review of resident council minutes indicated resident rights were not reviewed or discussed for the resident council meetings dated 11/06/2025, 12/04/2025, 01/08/2026, 03/05/2026, or 04/02/2026. Resident council minutes indicated only yes for the meeting on the date of 02/02/2026 and did not indicate what rights were reviewed. During an observation on 04/13/2026 at 3:15 PM of the facility bulletin board, resident rights postings were observed on the wall in English and Spanish. During a confidential interview at an undisclosed date and time, 8 confidential residents indicated staff had not discussed or reviewed their rights…

  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 · E2026-04-15 · tag F0576 — pattern
  Ensure residents have reasonable access to and privacy in their use of communication methods.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure residents were provided reasonable access to receive their mail in a timely manner for 8 of 8 confidential residents reviewed for mail. The facility failed to implement a system to distribute incoming mail daily and ensure residents promptly received their mail. This failure could place residents at risk of a delay in residents' personal correspondence, financial information, or other time-sensitive materials. The findings include: During a confidential group interview at an undisclosed date and time, 8 confidential residents indicated they did not receive mail on Saturdays. 8 confidential residents indicated if they were expecting mail on a Saturday they would expect to receive their mail that day. During an interview on 04/14/2026 at 1:28 PM the AD indicated she was responsible for ensuring residents receive their mail on weekdays. The AD indicated she went to the post office and obtained the mail and delivered it to residents throughout the week. The AD indicated she was unsure if the post office was open 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-04-15 · tag F0585 — failed to handle grievances — pattern
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  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 make information available to residents and their representatives on filing grievances for 7 of 8 confidential residents reviewed for grievances. The facility failed to ensure residents and their representatives had access to grievance forms and accommodations to file an anonymous grievance. This failure could place residents at risk of unresolved grievances and decreased quality of life. The findings include: An observation on 04/13/2026 at 3:15 PM revealed the facility had no grievance forms available for residents or their representatives freely available. The grievance policy was observed posted on the facility bulletin board and in English only. During a confidential group interview at an undisclosed date and time, 7 confidential residents indicated they were unaware of how to file a grievance. 7 confidential residents indicated they had never seen the grievance form. 8 confidential residents were unaware they could file an anonymous grievance. During an interview on 04/14/2026 at 1:15 PM, the AD…

  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 · E2026-04-15 · tag F0679 — failed to provide activities — pattern
  Provide activities to meet all resident's needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record review the facility failed to provide, based on the preferences of each resident, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 8 of 8 confidential residents reviewed for activities. The facility failed to provide activities to meet the residents' interests on the weekends. This failure could place residents at risk for a decline in quality of life and psychosocial well-being. The findings included: A record review on 04/13/2026 at 2:03 PM of the last 6 months, November 2025 through April 2026, activities calendars indicated there were no activities available for residents on Sundays for the months of November 2025, December 2025, January 2026, February 2026, March 2026, or April 2026. Every other weekend there was church available for residents and no activity scheduled for the alternate weekend for the months of November 2025, December 2025, January 2026, February 2026, March 2026, or April 2026. During a confidential interview at an undisclosed date and time, 8…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-04-15 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to ensure a system was established for records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determined that all drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 2 of 4 licensed nurse medication carts (100 and 300 hall carts) observed for pharmacy services. 1. The facility failed to ensure RN A did not sign the controlled substance count sheets for the end of their shift at the beginning of their shift on Cart #300 hall, on 04/14/2026. 2. The facility failed to ensure LVN B signed as receiving the controlled substance count sheets for his shift on Nurses Cart #100 on 04/14/2026. These failures could place residents at risk for medication diversion, administration of incorrect medication and compromised resident safety could place residents at risk of not receiving medications as ordered by the physician.Findings include: During an observation on 4/14/2026 at 1:49 PM, revealed 4/4…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  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 incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 2 of 3 residents (Resident #2 and Resident #3) reviewed for urinary catheters. The facility failed to ensure Resident #2's foley catheter was secured and/or anchored to prevent complications. The facility failed to ensure Resident #3's suprapubic catheter was secured and/or anchored to prevent complications. These failures could place residents with urinary catheters at risk for damage to the bladder or urethra, dislodging of the catheter, and urinary infections. Findings included: 1.Record review of a face sheet dated 04/15/2026 indicated resident #2 was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough 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 · Dcited before2026-04-15 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of four medication carts (Hall 100 medication cart) reviewed for labeling and storage. The facility failed to ensure LVN B locked the hall 100 medication cart when it was unattended. This failure could place residents at risk of drug diversion, administration of incorrect medication and compromised resident safety.Findings include: Observation on 4/14/2026 at 2:10 PM revealed the medication cart was at the nurse's station with the drawers closed but was unlocked and unattended for approximately five minutes, with no residents or visitors observed around the medication cart. During an interview on 4/14/2026 at 2:15 PM, the corporate nurse stated the cart should remain locked when unattended and it was left unsecured. During an interview on 4/14/2026 at 2:20 PM, LVN B said he stepped away 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-15 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #27 and Resident #65) reviewed for Infection Control. The facility failed to correctly identify residents who required EBP. The facility failed to provide consistent identification of residents who required EBP. The facility failed to ensure Resident #65 who had 2 (two) surgically inserted drainage tubes was on EBP. These failures could place residents at risk for the development and transmission of communicable diseases and infections. Findings included: 1.A record review of a face sheet dated 04/15/2026 indicated Resident #27 was an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included dementia and colostomy status. She had no diagnoses 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-29 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 24 hours after the allegation was made, for 1 of 3 residents (Resident's #1) reviewed for abuse and neglect. The facility failed to report an allegation of neglect on 01/19/2026 to HHSC within 24 hours. This failure could place the residents at increased risk for abuse and neglect.The findings included: Record review of the face sheet, dated 01/29/2026, reflected Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of hemiplegia (paralysis) and hemiparesis (weakness) following a stroke affecting the right dominant side. Record review of the admission MDS assessment, dated 11/17/2025, reflected Resident #1 had clear speech, was understood by others, and was able to understand others. Resident #1 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.

  Freedom from Abuse, Neglect, and Exploitation 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

$124,559 in federal fines across 6 penalties.

• $16,801 — penalty dated 2024-10-23
• $16,801 — penalty dated 2024-10-23
• $16,801 — penalty dated 2024-10-23
• $16,801 — penalty dated 2024-10-23
• $43,070 — penalty dated 2024-06-19
• $14,285 — penalty dated 2023-09-13

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 THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

This home reported $802K 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

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