Brookdale Galleria

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.

63.4% 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 303 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 75.5% 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 98 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 1.13 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 25% 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 56 beds and averages 42.1 residents a day — about 75% occupied, or roughly 14 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 4.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.09 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.91 hrs/resident/day on weekends vs 4.90 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.23 to 0.75 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% is well above 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.

27 citations, most serious first. The 15 most serious are shown; the remaining 12 are one tap away and print in full.

• Immediate jeopardy · J2026-03-23 · 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 to ensure each resident received adequate supervision for 1 of 8 residents (Resident #1) reviewed for adequate supervision. The facility failed to ensure that Resident #1 received adequate supervision when Resident #1 was able to exit the facility at 1:00am and found by staff on a busy street. An Immediate Jeopardy (IJ) was identified on 3.20.2026. The IJ template was provided to the Administrator on 3.20.2026 at 5:48 p.m. On 3/21/26 at 8:15pm, the Administrator was notified that the IJ was removed; however, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for possible serious injuries, harm and deathThe Findings include:Record review of Resident #1's undated face sheet, 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-04-04 · tag F0580 — failed to tell family and doctor about changes — pattern
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed immediately consult with the resident's physician when there is a significant change in the resident's physical status for 1 (Resident #1) of 5 residents reviewed physician notification. Facility staff identified sacral wound on Resident #1 on 2/16/2024 and facility staff failed to perform and document a wound assessment, notify the physician, and obtain wound care orders until 4 days later 2/20/2024. An IJ was identified on 4/1/2024. The IJ template was provided to the facility on 4/2/2024 at 4:14pm. The Immediate jeopardy was removed on 4/4/2024 due to the facilities implemented actions that corrected the non-compliance. This failure could affect residents with impaired skin integrity and residents at risk for impaired skin integrity of developing life threatening infections, hospitalization, and worsening pressure ulcers. Findings included: Record Review of Resident #1's Face Sheet undated revealed an [AGE] year old female who was admitted to 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-04-04 · 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 interview and record review the facility failed to ensure that a resident reviewed for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 1 (Resident #1) of 5 residents. 1. Facility staff identified sacral wound on Resident #1 on 2/16/2024 and facility staff failed to perform and document a wound assessment, notify the physician, and obtain wound care orders until 4 days later on 2/20/2024. Wound Care Physician assessed Resident #1 on 2/22/2024 and diagnosed Resident #1 with an unstageable (Due to Necroses) Sacrum Full Thickness pressure wound with a surface area of 129.72 cm. 2. Facility staff were performing dressing changes without a physician's order. An IJ was identified on 4/1/2024. The IJ template was provided to the facility on 4/2/2024 at 4:14pm. The Immediate jeopardy was determined to have been removed 4/4/2024 due to the facilities implemented actions that corrected the non-compliance.…

  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 · Gcited before2024-12-17 · 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 failed to ensure 1 of 6 residents (Resident #1) reviewed for wound care received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing, in that: - The facility failed to identify a healed area to Resident #1's sacrum which included a scab and pink skin when Resident #1 admitted to the facility on [DATE]. Appropriate interventions were not implemented for Resident #1 and the area developed into a pressure ulcer within approximately 12 days of admission and eventually developed into a Stage IV pressure ulcer. - CNA B stated she did not reposition the resident frequently enough while working with Resident #1 upon her first few days admission. This failure placed residents with low skin integrity at risk for skin breakdown or failure of wounds to heal. Findings included: Resident #1 Record review of Resident #1's face sheet reflected an [AGE] year-old female who was admitted…

  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 · Hcited before2023-12-11 · 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 residents received treatment and care in accordance with professional standards of practice to promote healing, prevent infection and prevent ulcers from developing for 1 (Resident #2) of 11 residents reviewed for treatment of pressure ulcer. -The facility failed to provide treatment in a timely manner for Resident #2 who experienced a decrease in skin integrity to the sacral region that resulted in an unstageable wound to the sacral region diagnosed by the wound care doctor on 12/1/23. -The facility failed to do consistent weekly skin assessments on Resident #2. -Facility failed to change Resident #2's dressing to sacrum on 12/06/2023 as ordered by the wound care doctor. These failures could place resident (s) who have wounds and at risk for skin impairment at risk for further decrease in skin impairment issues, infections, possible hospitalization, and decrease in quality of life. Findings: Record review of Resident #2 face sheet…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-11-25 · 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 ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the residents choices 1 of 5 residents (Resident #1) reviewed for quality of care. - The facility failed to ensure Resident #1 received orders for crushed medications as required after a speech therapy evaluation diagnosed him with dysphagia (difficulty swallowing) on 09/03/25 until 10/30/25.- The facility failed to ensure Resident #1 had orders to crush medications before administering crushed medications. This failure could result in resident's not receiving the care necessary, choking, and death. Findings include: Record review of Resident #1's Face Sheet dated 10/30/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included: kidney failure, difficulty walking, dementia, Parkinson's Disease (a…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-25 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  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 assessments accurately reflected the resident's status for 1 of 8 resident (Resident #1) reviewed for accuracy of assessments. - The facility failed to accurately document Resident #1's dysphagia (difficulty swallowing) that required a modified diet and crushed medications in his diagnosis and MDS. This failure could place residents at risk of inaccurate assessments, which could compromise their plan of care . Findings include: Record review of Resident #1's Face Sheet dated 10/30/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: kidney failure, difficulty walking, dementia, Parkinson's Disease (a brain disorder that affects movement, balance and coordination), stroke (interrupted blood flow to the brain that causes brain death) and history of stomach cancer. There was no documented diagnosis of dysphagia. Record review of Resident #1's admission Quarterly MDS 09/06/25…

  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 before2025-11-25 · 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 develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment describing services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Residents #1) reviewed for comprehensive care plans. - The facility failed to develop a care plan for Resident #1's diagnosis of dysphagia (difficulty swallowing) that required a modified diet and crushed medications in his diagnosis and MDS This failure could place residents at risk of not having their individual, medical, functional, and psychosocial needs identified and cause a physical, mental or psychosocial decline in health. Findings include: Record review of Resident #1's Face Sheet dated 10/30/25 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preference for 1 of 5 residents (Resident #2) reviewed for respiratory care. - The facility failed to ensure to change the water in Resident #1's oxygen concentrator (a machine that supplies concentrated oxygen) on 10/26/25 which resulted in the bottle being empty while the concentrator was in use and administering oxygen to the resident on 10/30/25. This failure could place residents at risk for dryness, irritation, nosebleeds, sore throats, thickened secretions, discomfort, and infection due to the dry oxygen. Findings include: Record review of Resident #2's Face Sheet dated 10/30/25 revealed, a [AGE] year-old female who admitted 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 before2025-11-25 · 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 interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurately documented for 1 of 5 residents (Resident #2) whose records were reviewed for resident identifiable records. - LVN A failed to document accurately when she documented a change of Resident #2's water used for her oxygen concentrator on 10/26/25 when she did not complete it. This failure could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings include Record review of Resident #2's Face Sheet dated 10/30/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: respiratory failure with hypoxia (low oxygen) and Hypercapnia (fast breathing), pneumonia (lung infection), COPD (group of breathing disorders that result in difficult breathing), and heart failure. Record review of Resident #2's admission MDS dated [DATE]…

  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 before2025-11-18 · 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 dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for pharmaceutical services.LVN C failed to remain in the room and monitor Resident #1's Family Member A administer medications to Resident #1. This failure could place residents at risk of not receiving the therapy needed. Findings included:Record review of Resident #1's admission MDS Assessment, dated 11 /14/25, reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses included spinal stenosis, lumbar region without neurogenic claudication (degenerative condition characterized by the narrowing of the spinal canal in the lower back), hypertension (high blood pressure), diabetes mellitus (disease that occurs when blood sugar are too high), and anxiety disorder (feeling 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-19 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for expired foods. The facility failed dispose of perishable foods after use in the walk-in fridge. This failure could place residents at risk for consuming hazardous expired food and developing foodborne illnesses who received food from the kitchen. Findings Included: Observation on 06/17/2025 at 10:48 AM revealed the following: *a bottle of Bay Leaves with use by date of 05/31/2025. * a package of Pork with use by date of 06/14/2025; *a package of Beef with use by date of 06/15/2025; *a package of Beef Tips with use by date of 06/10/2025; *a package of Brisket with use by date of 06/03/2025; and *a container of Chocolate Fudge Icing with use by date of 04/27/2025. An interview on 06/19/2025 at 11:22 AM with [NAME] A who revealed they have been trained on kitchen processes including discarding expired foods. [NAME] A stated that if there are expired foods in the…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-12-17 · 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 observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 1 resident (Resident #1) reviewed for infection. -The facility failed to ensure RN B performed hand hygiene during wound care for Resident #1. This failure could lead to the spread of infection to residents. Finding included: Record review of the admission sheet (undated) for Resident #1 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Fracture of left femur, history of falling, presence of left artificial hip joint, hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #1's Entry MDS, dated [DATE], revealed there was no section for BIMS score, functional status, urinary incontinence, 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-24 · tag F0638 — isolated
  Assure that each resident’s assessment is updated at least once every 3 months.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure for 1 of 12 residents (Resident #4) reviewed for resident assessments was assessed using the quarterly review instrument not less frequently than once every 3 months, in that: - Resident #4's EHR showed her quarterly MDS assessment was due for completion by 4/10/2024 but was not done by time of record review on 04/24/2024. This failure placed residents at risk of not receiving adequate care. Findings included: Record review of Resident #4's face sheet, dated, revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with vascular dementia, Parkinson's disease and protein calorie malnutrition. Record review of Resident #4's last comprehensive MDS, revealed it was dated 01/09/2024. Record review of Resident #4's EHR revealed the resident's quarterly ARD was due by 4/10/2024. In an interview with the MDS Nurse on 04/24/24 at 1:41PM, she stated assessment for admission assessments, quarterly assessments 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-04-24 · 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 1 of 6 residents (Resident #42) reviewed for pharmaceutical services. -The facility failed to administer the medication Esomeprazole (used to treat stomach acid related conditions) to Resident #8 on 04/21/2024, 04/22/2024 and 04/23/2024 as physician ordered. This failure could place residents receiving medication at risk of inadequate therapeutic outcomes and discomfort. Findings included: Record review of Resident #8's Diagnosis sheet dated 04/23/2024 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: GERD (gastro-esophageal reflux) and personal history of digestive system disease. Record review of Resident #8's annual MDS dated [DATE] revealed she had a BIMS score of 9 out of 10. She required substantial…

  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

$78,844 in federal fines across 4 penalties.

• $16,355 — penalty dated 2026-03-23
• $10,033 — penalty dated 2024-12-17
• $40,203 — penalty dated 2024-04-04
• $12,253 — penalty dated 2023-12-11

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 HEALTHPEAK PROPERTIES, INC. — 15 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 43 rows in the source record cover these 30 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

21 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 $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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 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