Bear Creek Nursing And 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.

60.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 145 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 57.5% 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 47 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.61 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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 74.1 residents a day — about 74% occupied, or roughly 26 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 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 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 2.99 hrs/resident/day on weekends vs 3.43 on weekdays — 13% thinner on weekends. RN hours go from 0.75 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% 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 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.

37 citations, most serious first. The 16 most serious are shown; the remaining 21 are one tap away and print in full.

• Immediate jeopardy · Kcited before2025-12-21 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were provided with pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for pharmacy services. The facility failed to have policies and processes in place to ensure the accurate dispensing and administering of medications. The admitting nurse for Resident #1 entered medications into Resident #1's medical record without verifying them against an accurate and current medication list, and the facility's physician subsequently signed the medication orders as entered. This resulted in Resident #1 being administered multiple doses of medications that were not prescribed to him. Resident #1 was found unresponsive and was subsequently sent to the hospital. On 12/20/25 at 6:10 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/21/25,…

  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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-12-21 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for one (Resident #1) of five residents reviewed for medication accuracy. The facility failed to ensure they had processes in place to ensure accurate verification and reconciliation of physician's orders and medications upon admission. The admitting nurse for Resident #1 entered medications into Resident #1's medical record without verifying them against an accurate and current medication list, and the facility's physician subsequently signed the medication orders as entered. This resulted in Resident #1 being administered multiple doses of medications that were not prescribed to him. Resident #1 was found unresponsive and was subsequently sent to the hospital. On 12/20/25 at 6:10 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/21/25, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-10-25 · 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 consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (Resident #1) of five residents reviewed for resident rights. The facility failed to notify the MD when Resident #1, who was a diabetic resident, had an elevated and abnormal lab with a blood glucose of 334 on 09/17/24, followed by a deterioration through 10/06/24 of his willingness to eat. Resident #1 had a change in condition which included him becoming unresponsive on 10/06/24. Resident #1 was sent to the hospital on [DATE] and was found to have a blood glucose reading of 1,139 (Normal glucose range for 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-10-25 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  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 has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #1) of five residents reviewed for neglect. 1. The facility neglected to ensure Resident #1 who was a diabetic resident, was accurately assessed, monitored and treated for a change in condition he had when he had an elevated and abnormal lab with a blood glucose of 334 on 09/17/24, followed by a deterioration through 10/06/24 of his willingness to eat. Resident #1 had a change in condition which included him becoming unresponsive on 10/06/24. Resident #1 was sent to the hospital on [DATE] and was found to have a blood glucose reading of 1,139 (Normal glucose range for a person with diabetes who has well-controlled levels is 72-99 while fasting and up to 140 about 2 hours after eating) and an Hemoglobin A1C (three month average of blood sugar) of 13 (normal range is below 5.7). 2. The facility neglected…

  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 · K2024-10-25 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #1) of five residents reviewed for quality of care. 1. The facility failed to ensure Resident #1 who was a diabetic resident, was accurately assessed, monitored and treated for a change in condition he had when he had an elevated and abnormal lab with a blood glucose of 334 on 09/17/24, followed by a deterioration of his willingness to eat then a change in condition which included him becoming unresponsive. At the hospital, Resident #1 was found to have a blood glucose reading of 1,139 (Normal glucose range for a person with diabetes who has well-controlled levels is 72-99 while fasting and up to 140 about 2 hours after eating) and an Hemoglobin A1C three month average of blood sugar) of 13 (normal range is below 5.7). 2. The facility charge nurses across all shifts failed to check 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-10-30 · 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 as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1, who had impaired cognition and was a high fall risk, was provided with adequate supervision to prevent her from eloping from the facility. On 10/16/23 Resident #1, who resided on the second floor and used a wheelchair for mobility, used the stairs to get to the bottom floor and was found outside of the facility. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 10/16/23 and ended on 10/20/23. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's face sheet, dated 10/30/23, 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.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · Ecited before2026-06-27 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to 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 3 of 4 Residents (Resident #1, Resident #2 and Resident #3) observed for infection control. The facility failed to ensure CNA A performed hand hygiene during incontinent care on Resident #1, Resident #2, and Resident #3 on 06/27/26. These failures could place the residents at risk of cross-contamination and development of infection.Findings included: 1. Record Review of Resident #1's Quarterly MDS assessment, dated 03/29/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. She had a BIMS score of 0 which indicated she was severely cognitively impaired. She required maximum assistance with transfers, toileting, and personal hygiene. She was frequently incontinent of urine and always incontinent 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-27 · 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 residents receive adequate supervision and assistance devices to prevent accidents for two of three residents (Resident #2 and Resident #3) reviewed for accident hazards/supervision/devices 1. The Facility failed to ensure CNA A and CNA B used a gait belt when transferring Resident #2 from her wheelchair to the bed and instead lifted the resident under her arms and by her pants on 06/27/26. 2. The Facility failed to ensure CNA A and CNA B used a gait belt when transferring Resident #3 from her wheelchair to the bed and instead lifted the resident under her arms on 06/27/26. These failures could affect the residents by placing the residents at risk for discomfort, pain, falls, injuries, and skin tears.Findings included: 1. Record Review of Resident #2's Quarterly MDS assessment, dated 04/21/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. She had a BIMS score of 0 which indicated she was severely cognitively…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-27 · 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 for two of four residents (Resident #1 and Resident #2) reviewed for incontinence care. 1. The facility failed to ensure staff provided Resident #1 timely perineal care after an incontinent episode when they failed to check and change the resident from 07:30 a.m. to 1:15 p.m. on 06/27/26. 2. The facility failed to ensure staff provided Resident #2 timely perineal care after an incontinent episode when they failed to check and change the resident from 07:45 a.m. to 1:30 p.m. on 06/27/26. This failure could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections.Findings included:1. Record Review of Resident #1's Quarterly MDS assessment, dated 03/29/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. She…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure residents are offered a therapeutic diet when there is a nutritional problem, and the healthcare provider orders a therapeutic diet for 1 of 4 residents (Resident #76) reviewed for food and nutrition. The facility failed to ensure Resident #76 received his nutritional supplement beverage (magic cup) during the lunch service on 05/06/26. This failure could lead to nutritional deficits and unintended weight loss. Findings include: Review of Resident #76's Quarterly MDS Assessment, dated 04/10/26, reflected he was a [AGE] year-old male who had recently readmitted to the facility on [DATE] after originally admitting on 10/30/25. He had a BIMS of 00 indicating severe cognitive impairment. His active diagnoses included malnutrition, adult failure to thrive, and cognitive communication deficit. His MDS indicated he had recently lost weight. Review of Resident #76's Order Summary Report, dated 05/07/26, reflected an order for Magic Cups two…

  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 before2026-05-07 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #85) reviewed for dialysis. 1. The facility failed to ensure dialysis communication forms were completed for Resident #85 after returning from dialysis treatment. 2. The facility failed to ensure Resident #85 had an order to complete dialysis treatment. These failures could place residents at risk of inadequate monitoring after returning to facility. Findings included: Review of Resident #85's None of the Above MDS Assessment, dated 04/26/26, reflected she was a [AGE] year-old who was admitted to the facility on [DATE]. Her MDS indicated she had a BIMS of 06, which meant she had severe cognitive impairment. Her active diagnoses included renal insufficiency, renal failure, or end-stage renal disease (the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-07 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 medication carts (Hall 300 nurse cart) reviewed for pharmacy services. The facility failed to ensure that one bottle of OTC Simethicone 125 mg, with an expiration date of February 2026, and Benzonatate 100 mg capsule prescribed to Resident #29, with an expiration date of 03/26/26, had been removed from the 300-hall nurse cart. This failure could place residents at risk of receiving medications that were ineffective. Findings included: Record review of Resident #29's Face Sheet, dated 05/07/26, revealed she was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #29's Quarterly MDS, dated [DATE], revealed she had the following diagnoses: COPD (progressive lung disease…

  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 before2026-05-07 · 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 observation, interview, and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 1 of 5 residents (Resident #76) records reviewed for accurate documentation. RN D failed to accurately document in Resident #76's clinical record when he documented on 05/06/26 that Resident #76 received his magic cup during the lunch meal when he had not received it. This failure could affect the residents medical record not being an accurate representation of the resident's medical condition or medical needs. Findings included: Review of Resident #76's Quarterly MDS Assessment, dated 04/10/26, reflected he was a [AGE] year-old male who had recently readmitted to the facility on [DATE] after originally admitting on 10/30/25. He had a BIMS of 00 indicating severe cognitive impairment. His active diagnoses included malnutrition, adult failure to thrive, and cognitive communication…

  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 · D2026-05-07 · tag F0849 — isolated
  Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and observation, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #13) reviewed for hospice services. The facility failed to ensure Resident #13, who was receiving hospice services, had a physician order for hospice care. This failure could place residents who receive hospice services at risk of receiving inadequate end-of-life care, coordination of care and communication of resident needs. Findings included: Record review of Resident #13's Face Sheet, dated 05/07/26, revealed she was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE].Record review of Resident #13's Quarterly MDS, dated [DATE], revealed she had 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-19 · tag F0585 — failed to handle grievances — isolated
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances and keep the residents' RP appropriately apprised of progress toward resolution for 1 of 6 residents (Resident #1) reviewed for grievances. The facility failed to notify Resident #1's RP the resolution of her filed grievances on [DATE]. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included:Record review of Resident #1's admission record, initially admitted on [DATE], reflected the resident was an [AGE] year old female with diagnoses that included vascular dementia (decreased blood flow to the brain), hypertension (the pressure in the blood vessels are consistently too high), irritable bowel syndrome (condition that affects stomach and intestines),. Record review of Resident #1's admission MDS assessment, dated [DATE], reflected Resident #1 had a BIMS score of 2 out of 15, which indicated severe cognitive impairment. Record review of Resident…

  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 before2025-11-19 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 6 residents (Resident #1) reviewed for medication storage. The facility failed to secure all medications in a locked storage area when Resident #1's Labetalol HCl and Pantoprazole Sodium medications were found on the floor approximately 2-3 inches from resident's bed on [DATE]. This failure could place residents at risk of access to medications not approved for administration by their physician. Findings included: Record review of Resident #1's admission record, initially admitted on [DATE], reflected the resident was an [AGE] year old female with diagnoses that included hypertension and irritable bowel syndrome. Record review of Resident #1's admission MDS assessment, dated [DATE], reflected the resident had a BIMS score of 2 out of 15,…

  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

“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

$122,257 in federal fines across 3 penalties.

• $48,945 — penalty dated 2025-12-21
• $65,866 — penalty dated 2024-10-25
• $7,446 — penalty dated 2023-10-30

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 EDURO HEALTHCARE — 34 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

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

Follow the money — this home’s finances

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

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX