Champions Healthcare at Willowbrook

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.

53.0% 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 164 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 76.3% 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 59 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 0.79 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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 98 beds and averages 83.1 residents a day — about 85% occupied, or roughly 15 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 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 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 3.02 hrs/resident/day on weekends vs 3.72 on weekdays — 19% thinner on weekends. RN hours go from 0.92 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.

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

Inspection trend

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.

18 citations, most serious first. The 13 most serious are shown; the remaining 5 are one tap away and print in full.

• Immediate jeopardy · L2025-02-25 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure comfortable and safe temperatures were maintained between 71F - 81F for 20 out of 20 residents (#2, #5, #9, #15, #17, #19, #21, #23, #24, #31, #35, #42, #45, #47, #49, #53, #57, #77, #140, and #190) reviewed for a safe and comfortable environment. - The facility failed to have a working heating system that provided heat to all resident rooms and used portable space heaters that did not monitor and adjust to room temperature but instead put out fixed heat, leaving some residents cold and room temperatures below 71 degrees Fahrenheit. - Observations and temperature measurements of resident rooms in the 100-hall ranged from 67.1 to 70.4 degrees Fahrenheit. - Observations and temperature measurements of resident rooms in the 200 hall ranged from 64.6 to 70.2 degrees Fahrenheit. - Facility records reported temperature measurements as low at 64 degrees Fahrenheit. An IJ was identified on (02/19/25). The IJ template was provided to the…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2026-04-23 · 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 resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation for 2 of 5 (Resident #44 and Resident #35) residents reviewed for abuse.The facility failed to protect Resident #44 from being slapped in the chest by Resident #35, in the hallway near the dining room, on 04/13/2026The failure placed residents at risk of injuries and psychosocial harm. Findings included:Record review of Resident #35's undated face sheet revealed a [AGE] year-old female who admitted into the facility on [DATE] with a recent admitted date of 04/15/2026. She had diagnoses of dementia, intellectual disabilities, convulsions, panic disorder, psychotic disorder, restlessness and agitation, and personal history of mental and behavioral disorders.Record review of Resident #35's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 06 out of 15 indicated severe cognitive impairment to reflect significant…

  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
• Actual harm · G2026-04-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  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 is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 5 residents (Resident #66) reviewed for ADL care.The facility failed to ensure LVN R assisted Resident #66 off the bedpan in a timely manner on 4/20/26, causing physical and emotional pain to the resident.This failure could place the residents at risk of decreased feelings of self-worth and pain.Findings included:Record review of Resident #66's face sheet dated 08/23/26 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnosis included injury of muscle, fascia and tendon of the posterior muscle group at thigh level, muscle weakness, and reduced mobility.Record review of Resident #66's 5-day MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated intact cognition. She had range of motion impairment of the lower extremity on one side. She was…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-04-23 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 2 (1st floor kitchen) kitchens reviewed for food service safety.The kitchen staff failed to check temperatures before meal service to ensure food were held at safe temperatures in the 1st floor kitchen (main kitchen).This deficient practice could place residents at risk for foodborne illness due to unsafe temperatures.Findings included:During an observation on 04/22/2026 at 12:11pm in the Main Kitchen on the 1st floor, revealed beef liver and onions with gravy, wheat dinner rolls, seasoned potatoes, chicken fingers, green peas, and mashed potatoes were the foods being prepped and plated. At 12:22pm the first plate was dished up and placed on the service rack for delivery to residents in the dining room, and temperature checks were not conducted beforehand.During an interview on 04/22/2026 at 12:40pm with the DM, he stated that he started the position two weeks ago and could only locate temperature logs for March 2026,…

  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 before2026-04-23 · 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 8 residents (Resident #16) reviewed for pharmacy services.LVN E did not ensure the accurate administration of Novolog and Lantus insulins (a hormone to help regulate blood sugar levels of individuals who have diabetes) per manufacturer's instructions. LVN E did not prime the insulin pen (removing air bubbles from the needing) prior to administering to Resident #16 on 04/22/26.LVN E did not ensure the accurate administration of Novolog (a rapid acting insulin) and Lantus (a long acting insulin) per manufacturer's instructions. LVN E held the insulin pen injectors against Resident #16's skin for 2 seconds after injection, instead of the manufacturer's recommended time for each insulin, on 4/22/26. LVN E did not ensure Resident #16 rinsed…

  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 before2026-04-23 · 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 to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature control, and only permit only authorized personnel to have access to the keys for 2 of 5 residents (Resident #42 and Resident #57) reviewed for storage of medications.The facility failed to keep Resident #42 and Resident #57's medications secured.The deficient practice could place residents at risk of not receiving the therapeutic benefit of medications, drug diversion, or ingestion of unprescribed medications to residents, staff, and visitors.Findings included:Record review of Resident #57's undated face sheet revealed a [AGE] year-old male who admitted into the facility on [DATE] and readmitted on [DATE]. He had diagnoses of chronic respiratory failure, pulmonary fibrosis (chronic lung disease), diabetes, dementia, and congestive heart failure.Record review of Resident #57's MDS assessment dated [DATE] 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-23 · 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 ensure the residents medical records were accurate for 1 of 5 (CR #1) residents reviewed for medical records The facility failed to update CR #1's advance directive and care plan after receiving a completed DNR form from the physician and responsible party.This failure could cause a violation to the residents' right to self-determination.Findings included:Record review of Resident CR #1's undated face sheet revealed a [AGE] year-old male who admitted into the facility on [DATE]. His diagnoses included hypertension (high blood pressure), malignant neoplasm of the liver (liver cancer), dementia, and malnutrition.Record review of Resident CR #1's physician orders dated [DATE] revealed full code: use AED with CPR during sudden cardiac arrest.Record review of Resident CR #1's MDS assessment dated [DATE] revealed a BIMS score 06 out of 15 indicated moderate to severe cognitive impairment to reflect significant difficulty with short term memory, recall, 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 before2026-04-23 · 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 did not maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 8 residents (Resident #52, # 17 and #98) reviewed for infection control. MA D failed to sanitize the automated blood pressure cuff used between Residents #52, #17 and #98 when checking blood pressures during medication pass.This deficient practice could affect residents needing blood pressure checks and place them at risk of cross contamination and infection. Record review of Resident #52's face sheet dated 4/23/26 revealed a [AGE] year-old admitted the facility on 10/30/24 and initially admitted on [DATE] with diagnoses to include dementia (a decline in cognitive function), hypertension (elevated blood pressure), stroke, heart failure, anemia, and chronic kidney disease.Record review of Resident #52's quarterly MDS resident assessment…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-17 · 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 provide pharmaceutical services to assure the accurate dispensing, and administering of all drugs to meet the needs for 2 of 5 residents (CR#1 & CR# 2) reviewed for medication administration, in that: The facility failed to ensure that CR#1's and CR#2's received their medications as ordered by their physician. This failure could place residents at risk of been overmedicated or undermedicated and not getting the therapeutical effect of the medications to improve their quality of life. Record review of CR#1's admission record dated 3/17/2026 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cognitive communication (not able to communicate clearly), Type 2 Diabetes (high blood sugar), hypertension (high blood pressure), chronic kidney disease (a condition where the kidneys are damage and are unable to filter waste from the blood) and insomnia (difficulty sleeping). Record review of CR#1's MDS…

  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 · Ecited before2025-12-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to prepare, store, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. 1) The facility failed to properly seal food product bags in the dry storage area to prevent exposure to air. 2) The facility failed to store food thickener items six inches off the floor and ensured it was not exposed to air. 3) The facility failed to maintain the proper temperature of the high heat sanitizing dish machine. The failures could have placed residents at risk for food contamination and foodborne illness.Findings included: Observation of the kitchen's dry food storage area on 10/28/2025 at 9:05 am revealed there was a bag of pasta noodles opened and exposed to air There was also a box of food thickener powder that was open, exposed to air, sitting on the floor by the shelf. Observation/Interview with DA A on 10/28/2025 at 9:45 am revealed that he had been washing dishes since 6:00am. He said the temperature on the dish machine was…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-12-09 · 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

  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 3 staff reviewed for infection control. 1. CNA E failed to perform hand hygiene when passing lunch trays on the 100 hall. 2. The DM did not conduct hand hygiene before giving Resident #5 her lunch tray, hugged another resident, and went to another resident. The DM then went from one resident to another doing a fist bump and shaking hands in between handing out resident trays and did not conduct handwashing or hand hygiene. 3. CNA F did not sanitize her hands between residents' trays and touched her clothes twice. These failures have the potential to affect all residents in the facility by exposing them to infection that could lead to the spread of viral or secondary infections and communicable diseases. Findings included: An observation on 10/28/25 at 12:15 pm revealed CNA F did not…

  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 · D2025-12-09 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 10 (Resident #5) residents reviewed for dining services in 1 of 1 dining room. The facility failed to promote Resident #5's dignity on 10/28/2025 while dining when staff did not serve the resident her lunch tray at the same time as other residents at the same table. This failure could affect all residents who eat in the dining room, by contributing to poor self-esteem, and unmet needs. Findings included: Review of Resident #5's Face Sheet dated 10/28/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5's diagnoses included heart failure, type 2 diabetes mellitus with unspecified complications (high blood sugar), hypertension (high blood pressure), cerebral infraction (stroke), convulsions (sudden 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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-14 · 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 [NAME], Kymyaka Based on record review and interview the facility staff failed to ensure residents with pressure ulcers received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 6 residents (CR#1) reviewed for wound care. -The facility failed to obtain wound care orders for CR#1's sacral wound upon admission from 06/11/2024-06/17/2024, and failed to document that the orders were implemented once obtained from 06/17/2024-06/20/2024. This failure could place residents at risk of not receiving adequate care in a timely manner, deterioration of skin, and decreased quality of life. Findings included: Record review of CR#1's Face Sheet dated 6/21/2024 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of fracture of upper end of left humerus (upper arm fracture). CR#1 discharged to a local hospital 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$44,335 in federal fines across 2 penalties.

• $13,065 — penalty dated 2026-04-23
• $31,270 — penalty dated 2025-02-14

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

Part of a chain

This home belongs to 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 16 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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 $625K 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