Focused Care at Beechnut

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 146 beds and averages 119.2 residents a day — about 82% occupied, or roughly 27 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 2.96 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.23 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 2.63 hrs/resident/day on weekends vs 3.09 on weekdays — 15% thinner on weekends. RN hours go from 0.25 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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.

33 citations, most serious first. The 20 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-04-17 · 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, interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (CR #1) reviewed for accidents and supervision, in that:The facility failed to ensure CR #1 did not elope from the facility on 3/21/26. The facility did not realize he had left through a window in room [ROOM NUMBER] and exited the facility through the fence. Resident #1 was found by a staff member in front of a store located approximately 2.5 miles away.The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 03/21/26 and ended on 03/21/26. The facility had corrected the non-compliance before the survey began on 04/15/26. The IJ template was sent to the Administrator on 04/16/26 at 3:18 p.m.This failure could have placed residents with exit-seeking behaviors at risk for injury or death.Findings included:Record review of CR #1's face sheet dated 04/15/26 revealed a [AGE] year-old male who was 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 · Past Non-Compliance
• Immediate jeopardy · Jcited before2024-08-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for one of twenty-one residents (Resident #1) reviewed for accident hazards and supervision. -The facility failed to ensure Resident #1 had adequate supervision on 8/16/2024 which allowed her to elope from the facility. She was not found until 8/17/24 when she was admitted to the emergency room with complaints of heat exhaustion and weakness. The noncompliance was identified as past noncompliance and the Administrator was given the IJ Template on 8/29/24 at 2:23 pm. The IJ began on 8/16/2024 and ended on 8/18/2024. The facility had corrected the noncompliance before the investigation began on 8/18/2024. These failures could place residents at risk of serious injury or harm. Findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old woman admitted 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 · Past Non-Compliance
• Immediate jeopardy · Kcited before2024-07-02 · 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 observations, interviews, and record review, the facility failed to immediately consult with the physician and notify the resident representative when the resident experienced a change in condition for 1 of 5 residents (Resident #72) reviewed for a change of condition. The facility failed to notify the physician regarding Resident #72's missed urologist appointments on 3/14/2024 and 5/23/24, and failed to communicate Resident #72's changing skin condition of the groin and resident's report of pain until around 06/10/2024, at which time the penis split measured 8 cm length by 1 cm width by .4 cm depth and appeared red and raw. On 6/28/24 at 5:44PM an Immediate Jeopardy (IJ) was identified and the template was presented to the Administrator and the Interim DON. While the IJ was removed 7/2/2024 at 3:45PM, the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan…

  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 · K2024-07-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
  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 observations, interviews, 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 2 of 4 residents (Resident #72 and #54) reviewed for quality of care. 1. The facility failed to assess, follow-up with treatment, update the care-plan, obtain new order due to a change in resident # 72's skin condition of the groin and resident's report of pain, at which time the penis split measured 8 cm length by 1 cm width by .4 cm depth and appeared red and raw, and failed to ensure that Resident #72's indwelling catheter (drains urine from your bladder into a bag outside your body) had a securement device to anchor catheter. 2. The facility failed to ensure that CNA B changed her gloves and perform hand hygiene while providing indwelling catheter and incontinent care to Resident #72. On 6/28/24 at 5:44PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 6/30/2024 at 12:27 pm, 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
• Immediate jeopardy · Kcited before2024-05-03 · 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 to immediately consult with the physician and notify the resident representative when the resident experienced a change in condition for 1 of 22 residents (CR #1) reviewed for a change of condition: -The facility failed to immediately inform CR#1's physician after a change in condition. -The facility failed to notify the Physician when CR #1 had a choking episode on 04/22/24 and experienced a change in condition. -The facility failed to notify CR #1's RP when she experienced a change in condition - CR #1 passed away on 04/27/202418 at the hospital. An IJ was identified on 04/29/24. The IJ template was provided to the facility on [DATE] at 12:54 PM. While the IJ was removed on 05/03/2024 at 12:24PM, the facility remained out of compliance at a scope of isolated and a severity of harm with potential for more than the minimal harm that is not an immediate jeopardy because all staff had been trained on to notify the physician when a resident experience 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 · Kcited before2024-05-03 · tag F0656 — failed to write and follow a full care plan — pattern
  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 interview and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 22 residents (CR #1) reviewed for care plans. - The facility failed to ensure CR #1 had a Comprehensive Care Plan to address her diagnosis of dysphagia (difficulty swallowing). -The facility failed to have interventions in place when CR #1 experienced a choking episode on 04/22/2024. On 04/25/2024 CR #1 experienced another choking episode and was transferred to the hospital. - CR #1 passed away on 04/27/2024 at the hospital. An IJ was identified on 04/29/24. The IJ template was provided to the facility on [DATE] at 1:07PM. While the IJ was removed on 05/02/2024 at 5:17PM. While the IJ was removed on 05/02/2024, the facility remained out of compliance at a scope of isolated and a severity of harm because all staff had not been…

  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
• Immediate jeopardy · Kcited before2024-05-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents received adequate supervision and assisted device to prevent accidents for 1 of 22 residents (CR #1) reviewed for accidents. -The facility failed to intervene by putting interventions in place when CR #1 began having choking episode during eating on 04/22/24. -The facility failed to in-service staff on the s/s of silent aspiration and choking. -The facility failed to monitor CR #1 during meals after she had a choking episode on 04/22/24. CR #1 experienced another choking episode on 04/25/2024 and had to be transferred to the hospital via 911services. CR #1 passed away at the hospital on [DATE]. This failure could place residents at risk for choking/silent aspiration that could lead to death. An IJ was identified on 04/29/24. The IJ template was provided to the facility on [DATE] at 1:07PM. While the IJ was removed on 05/03/2024 at 12:24PM, the facility remained out of compliance at a scope of isolated and a severity 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-02-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 10 residents (CR #1) reviewed for Quality of Care. 1.The facility failed to immediately transfer CR #1, who was cognitively impaired and received Eliquis (an anticoagulant/blood thinner) when CR #1 went to the hospital after an unwitnessed fall on 09/22/2023 at 4:55 a.m. and sustaining a head injury. CR #1 was transferred to the hospital via non-emergency transportation service as a replacement for 911 emergency services. An Immediate Jeopardy (IJ) was identified on 01/18/2024 at 10:49 a.m. The IJ template was provided to the facility on [DATE] at 10:49 a.m. While the IJ was removed on 01/19/2024, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need 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
• Immediate jeopardy · Jcited before2024-02-08 · 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 accidents and hazards as is possible for 22 of 22 residents reviewed for accidents and hazards. 1. CNA B and CNA C engaged in a verbal and physical altercation in the presence of at least two residents, Resident #2, and Resident #3 on 1/18/24 at approximately 6:00 a.m. 2. CNA C left a loaded firearm unattended inside her personal bag in an unsecured cabinet under the nurse's station desk located directly across from a resident TV area for an undetermined amount of days/time. 3. CNA C pointed a loaded firearm at CNA B and discharged the gun outside in the air approximately one yard from resident-occupied rooms on 1/18/24. An Immediate Jeopardy (IJ) was identified on 02/07/2024 at 9:40 a.m. The IJ template was provided to the facility on [DATE] at 9:40 a.m. While the IJ was removed on 02/08/2024 , the facility remained out of compliance at a scope of isolated with the potential for…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2023-04-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent accidents for 5 of 15 residents (Residents #321, #80, #34, #43, and #53) reviewed for accidents and supervision. 1. The facility failed to ensure the memory care courtyard gate was locked. Resident #321 left the courtyard through the unlocked gate, after being left unsupervised by the MA A, and was headed toward the front of the facility. 2. The facility failed to train staff to monitor the memory care courtyard gates to ensure they were locked. 3. The facility failed to ensure Resident #80 (a resident with quadriplegia and the inability to hold his own cigarette without staff assistance), Resident #34, Resident #43 and Resident #53 were supervised during smoke breaks. An Immediate Jeopardy (IJ) situation was identified on 4/20/2023 at 4:18 p.m. While the IJ was removed 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
• Potential for harm · Fcited before2025-08-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that:1-10 pounds roll of Ground Beef had a temperature of 75 degrees Fahrenheit.This failure could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease.Observation and interview on 08/19/25 between 8:30 am and 8:40 am with the Dietary Manager revealed 1-10 pounds roll of ground beef observed. The roll was a potentially hazardous/time control for safety food as it was inappropriately being held on a pan on top of the stove. The Dietary Manager measured the roll on the stove, and it had an internal temperature 75 degrees Fahrenheit.Interview with the Dietary Manager on 08/19/25 at 8:40 AM he stated that food held with danger zone temperature could place the residents who ate food at risk of food borne illness and disease. He stated that he was responsible for training staff on proper storage 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-08-22 · tag F0814 — failed to dispose of garbage properly — widespread
  Dispose of garbage and refuse properly.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 4 of 4 dumpsters reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured.This failure could place residents at risk of infection. Observation on 08-19-25 at 8:45 am, with the Dietary Manager revealed the facility's dumpster area, which was in the lot behind the dietary department had 4 commercial -size dumpsters and the lids and doors were open. Interview on 08-19-25 at 9:00 am, with the Dietary Manager he stated that the dumpster lids always must be closed to keep vermin, pests and insects out of the dumpster and from entering the facility. He also stated that nursing, housekeeping and dietary dispose their garbage in the dumpster and place residents at risk of infection.Record review of facility policy and procedure on Waste Disposal dated June 2006, revealed: Policy, Food related garbage and rubbish is disposed of in accordance with current laws and regulations. Outside dumpster provided by garbage pick- up services will be…

  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 · E2025-08-22 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
  Reasonably accommodate the needs and preferences of each 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 observations, interviews and record review, the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs for 3 of 5 residents (Residents #103, #101, and #36) reviewed for call lights.-The facility failed to ensure Resident #103, Resident #101's, and #36's call lights within reach.This failure could place residents at risk for a delay in care and services, increased falls, and a decreased quality of life.Resident #103Record review of Resident #103's face sheet 08/22/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #103 had diagnoses which included: diabetes mellitus (high blood sugar), hypertension (high blood pressure), and Alzheimer (a progressive brain disease that cause memory loss). Record review of Resident #103 's Quarterly MDS assessment dated [DATE] revealed BIMS score of 00 of 15 indicating severely impaired cognition. Further review revealed the resident needed total care with ADL assistance with…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-08-22 · 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 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 infections for 3 of 4 residents (Resident #103, Resident #34, and Resident #1) and 1 (Station A) of nurse's stations reviewed for infection control. 1. The facility failed to ensure CNA U followed appropriate infection control and hand hygiene procedure during incontinent care for Resident #103. 2. The facility failed to ensure LVN Z followed appropriate infection control and hand hygiene procedure during Accu check for Resident #34.3. The facility failed to ensure CNA R and LVN B followed appropriate infection control and PPE when Resident #1's Foley bag and tubing was lying on the floor, and no PPE was in the set up. 4. LVN A failed to wash her hands and follow sterile techniques while providing Resident #10 with tracheostomy…

  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 · E2025-08-22 · tag F0919 — failed to provide a working call system — pattern
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  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 be adequately equipped to allow residents to call for staff assistance through a communication system for 1 of 5 residents (Resident #103) reviewed for call light button placement and for 3 (102, 104, and 105) of 4 resident doors reviewed for working call lights systems.The facility failed to ensure Resident #103's call light was functioning properly. The facility failed to ensure emergency call lights in the restroom was illuminated over 3 doors of rooms 102, 104 and 105 on 8/19/25These failures could place residents at risk of not being able to call for assistance when needed. Findings include: 1. Record review of Resident #103's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #103 had diagnoses which included: diabetes mellitus (high blood sugar), hypertension (high blood pressure), and Alzheimer's (a progressive brain disease that cause memory loss). Record review of Resident #103 '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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-22 · tag F0925 — failed to control pests — pattern
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed was free of pests and rodents for the months of March 2025 and August 2025 reviewed for environment.-The facility failed to ensure the facility was free of roaches in the dining room, residents' rooms, nursing station and in the dietary department. These failures could place residents at risk of disease, infection and a decline in their physical health. Roaches were observed in the dining room, resident's rooms, nursing station and in dietary department. 2. During the group interview, some residents complained about roaches they had observed a month ago. Interview with the Dietary Manager on 08-19-25 at 9:00AM revealed that the department had issues on roaches and gnats last month, but the issue is getting better. The walls and baseboards of the kitchen appeared to be sealed with no concerns. Observation on 08-20-25 at 2:30pm, this Surveyor along with RN A sighted a small roach at the nursing station. During confidential interviews between…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-22 · tag F0640 — isolated
  Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 Record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after a facility completes the resident's assessment for 1 (CR #59) of 3 resident reviewed for MDS transmission. -The facility failed to transmit a completed Discharge MDS assessment for CR# 59 within 14 days of completion.These failures could place residents at-risk of not having their assessment and care plan completed timely, which could result in denial of services and or payment for services.Record review of CR# 59's admission Record dated [DATE] revealed a [AGE] year-old male. CR# 59 had an admission date of [DATE] and discharge date of [DATE]. CR #59 diagnoses included other cerebral palsy (refers to the types beyond the most common, Spastic Cerebral Palsy, and includes Dyskinetic Cerebral Palsy, which involves involuntary, uncontrolled movements like writhing or muscle spasms, and Ataxic Cerebral Palsy, which affects balance and coordination due to brain damage…

  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 before2025-08-22 · 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 includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Residents #15 and #78) reviewed for comprehensive care plans. 1. The facility failed to care plan Resident #15 being placed back into the secured unit on 07/31/2025. 2. The facility delayed care-planning Resident #78 for being on hospice after she was admitted on [DATE]. She was care-planned on 4/24/2025.This failure could lead to residents not having their individual, medical, functional, and psychosocial needs identified and cause a physical, mental or psychosocial decline in health. Resident #15Record review of…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-22 · 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

  Based on observation, interview and record review, the facility failed to ensure that resident environment remains as free of accident hazards as is possible for 1 (Resident #76) of 4 residents and 1 of 3 medication carts reviewed for accident hazards. -The DPS (Maintenance Director) left a portable flashlight with its light turned on and unsecured in Resident #76's bathroom on 09/21/2025. - The facility failed to properly dispose a blue disposable razor/shaver, and a syringe used for injections within the sharps contain attached to the side of 1 (station A) of 3 medication carts.These failures could put residents at potential risk of harming themselves or others with unsecured equipment. Findings included:Record review of Resident #76's care plan dated 08/22/2025, Resident #76 had a focus area for impaired cognitive function, cognitive loss and impaired decision-making abilities with interventions including monitoring, documenting and report as needed any changes in cognitive functions and changes in memory, general awareness and decision-making ability.Observation of Resident #76…

  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 before2025-08-22 · 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 who needs respiratory care, including tracheotomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #10) of two residents reviewed for tracheotomy care.-The facility failed to ensure LVN A used sterile technique during tracheotomy suctioning for Resident #10 on 8/20/25.This failure placed residents who required respiratory care at risk for respiratory infections, hospitalizations, and a decline in their quality of life. Record review of Resident #10's face sheet revealed he was a [AGE] year-old male who was originally admitted on [DATE] and re-admitted [DATE]. His medical diagnoses included cerebral infarction,( a problem that affects muscle tone, movement, and coordination) tracheostomy status,( a procedure to help air and oxygen reach the lungs by creating an opening…

  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

$90,403 in federal fines across 4 penalties.

• $16,240 — penalty dated 2024-08-29
• $49,277 — penalty dated 2024-07-02
• $16,716 — penalty dated 2024-05-03
• $8,170 — penalty dated 2024-02-08

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 FOCUSED POST ACUTE CARE PARTNERS — 25 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 20 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

About 88% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $448K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

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

What families pay in TX