Garden Terrace Healthcare Center of Houston

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.

57.7% 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 207 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 85.9% 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 99 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 0.89 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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 120 beds and averages 53.0 residents a day — about 44% occupied, or roughly 67 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.33 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.99 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 3.60 hrs/resident/day on weekends vs 4.62 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.12 to 0.66 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% 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 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.

21 citations, most serious first. The 14 most serious are shown; the remaining 7 are one tap away and print in full.

• Immediate jeopardy · K2025-12-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  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 needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preference for 1 (Resident #1) of 3 residents reviewed for tracheal care. The facility failed to follow physician orders for Resident #1 by not performing the prescribed trach care as ordered. Specifically, the facility did not change the trach aerosol tubing, mask, jet nebulizer bottle, and water trap every Sunday on nights shift or change the trach ties every night shift on 10/11/25, 10/12/25, 10/13/25, 10/18/25, 10/19/25, 10/25/25, 10/26/25, 11/2/25, 11/3/25, 11/4/25, 11/5/25, 11/6/25, 11/7/25, 11/8/25, 11/9/25, 11/16/25, 11/23/25, 11/24/25, and 11/27/25. On 11/28/25, Resident #1 was admitted to the hospital due to brown emesis coming from his mouth and trach and Resident #1 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
• Immediate jeopardy · Kcited before2024-07-10 · 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 receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (Resident #1) of 5 residents whose records were reviewed for pressure ulcer care. 1. The facility failed to minimize Resident #1's exposure to moisture and keep the skin clean of fecal contamination, after the resident was discovered to have moisture associated skin damage to her sacral region. 2. The facility failed to implement Resident #1's wound care treatment orders to a facility acquired wound to her sacral region, which led to the decline of the wound from a stage III to a stage IV pressure ulcer. Resident #1 was admitted to the hospital with a diagnosis of sepsis, Staphylococcus aureus, and gram-negative rods. An IJ was identified on 07/04/24 at 5:27 pm. The IJ template was provided to the facility 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
• Actual harm · Hcited before2023-11-01 · 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 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 2 of 6 residents (CR #1 and Resident #1) reviewed for pharmacy services in that: - The facility failed to administer pain medications to Resident #1 as ordered upon admission after the resident reported pain at 10 out of 10. - The facility failed to acquire and administer medications to Resident #1 as ordered upon admission, with some seizure meds not administered until 2 days after admission. - The facility failed to accurately administer Resident #1's seizure medication Clobazam as ordered by administering Clobazam 10 mg tablets instead of 5mg films as documented in the EMR - The facility failed to retrieve Resident #1 initial dose of medications from the facility emergency kit. - The facility failed to administer medications timely to Resident #1. - 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-01 · 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 provide necessary treatment and services to promote healing and prevent worsening pressure sores for 1 of 7 residents (CR#1) reviewed for pressure sores. -The facility failed to enter orders and provide wound care for CR #1's sacrum upon admission resulting in the resident going from shearing/redness to a stage 3 pressure ulcer. This failure could place residents at risk of worsening of current sores or the development of new pressure sores. Finding Included: Record review of CR #1's Face Sheet dated 10/25/23 at 11:42 AM revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: femur fracture and an encounter for orthopedic aftercare. The resident was transferred to the hospital on [DATE] and never returned to the facility. Record review of CR #1's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 01 out of 15. Record review of CR #1's Hospital Records dated 08/02/23 at…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-22 · 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 and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #5) reviewed for comprehensive care plans. 1. Resident #5's care plan was not followed when he was transferred from his wheelchair to his bed with one-person assist and without a gait belt present on 05/22/2026 when he was care-planned for a two-person transfer with a gait belt. This failure could lead to residents not having their individual medical and physical needs met and lead to a decline in health.Record review of Resident #5's face sheet dated 05/21/2026, reflected he was a [AGE] year-old male…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-22 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #5) reviewed for accident hazards. -Resident #5 was transferred by CNA M with a one-person transfer and without a gait belt from wheelchair to bed on 5/22/26. This failure could place residents at risk of injury from unsafe transfers.Record review of Resident #5's face sheet dated 05/21/2026, reflected he was a [AGE] year-old male initially admitted on [DATE] with hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness following a stroke), difficulty in walking, generalized muscle weakness and bilateral primary osteoarthritis in hip (pain in bone and joints in both hips) and a urinary tract infection (onset date 05/06/2026). Record review of Resident #5's Comprehensive 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for 1 of 5 residents (Resident #5) reviewed for incontinent care. -CNA M and LVN G provided incontinent care for Resident #5 without changing gloves and sanitizing their hands in-between cleaning Resident #5's penis during wiping. These failures could cause residents to be at risk of urinary tract infection, pain, injury, poor hygiene, and hospitalization.Record review of Resident #5's face sheet dated 05/21/2026, reflected he was a [AGE] year-old male initially admitted on [DATE] with hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness following a stroke), difficulty in walking, generalized muscle weakness and bilateral primary osteoarthritis in hip (pain in bone and joints in both hips) and a urinary tract infection (onset date 05/06/2026). Record…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-22 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to keep confidential all information contained in the resident's records, regardless of the form or storage method of the records and safeguard medical record information against loss, destruction, or unauthorized use for 1 of 5 residents (Resident #2) observed for privacy. -RN V left Resident #2's empty blister pack on the medication cart which could be observed by anyone walking by on 05/22/2026. This failure could put residents at risk of their personal health information being exposed to unauthorized personnel.Record review of Resident #2's face sheet dated 05/22/2026, reflected she was an [AGE] year-old female initially admitted on [DATE] with medical diagnoses including acute respiratory failure with hypoxia (not enough oxygen), muscle weakness, malignant neoplasm of unspecified site of left female breast (cancer in the left breast) and chronic kidney disease. Record review of Resident #2's physician's order summary dated 05/22/2026,…

  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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-22 · 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 maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 (Resident #5) of 5 residents observed for infection control. -There was a breakfast tray left out in an open dining area on 05/21/2026 at 1:36p.m. -CNA M and LVN G provided incontinent care for Resident #5 without changing gloves and sanitizing their hands in-between cleaning Resident #5's penis and touching Resident #5's personal and physical environment and Resident #5's skin. These failures could have placed residents at risk by exposing them to care that could have led to the spread of infections, secondary infections, or communicable diseases.Record review of Resident #5's face sheet dated 05/21/2026, reflected he was a [AGE] year-old male initially admitted on [DATE] with hemiplegia and hemiparesis following cerebral infarction…

  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 · D2026-04-06 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  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 a person-centered baseline admission care plan for 1 of 3 residents (Resident #2) reviewed for baseline care plans in that:-The facility failed to develop a baseline care plan with goals, interventions, treatments, and psychosocial needs within 48 hours of admission for Resident #2.This failure could have affected new admission residents by not having their individual, medical, functional, and psychosocial needs identified and could cause a physical or psychosocial decline in health.Record review of Resident #2's face sheet dated [DATE] revealed she was an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included: fracture of the lower end of radius (broken wrist injury), hypertension (high blood pressure), and dementia (decline in mental ability).Record review of Resident #2's 15-day MDS assessment dated [DATE] revealed a BIMS score of 00 out of 15, indicating…

  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 before2026-04-06 · 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 assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, and a system of medication records that enabled periodic accurate reconciliation and accounting of all controlled medications to meet the needs of 1 of 3 residents (Resident #1) reviewed for pharmacy services, in that:The facility failed to ensure Resident #1's control count sheet matched with the actual Lacosamide liquid medication.This failure could have placed residents at risk of not receiving their adequate dose of medication and drug diversion. Findings included:Record review of Resident #1's face sheet dated 4/06/26 revealed she was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included: diabetes mellitus (high blood sugar levels), hypertension (high blood pressure), and cerebral infarction (blockage in an artery supplying 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-19 · tag F0628 — pattern
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  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 provide and document sufficient preparation and orientation of residents to ensure safe and orderly transfer or discharge from the facility for 2 of 5 resident (CR#1 and CR # 2) reviewed for transfer, discharge rights, and discharge summary. - LVN P failed to complete a discharge summary for CR #1 - LVN M failed to complete a discharge summary for CR #2. These failures could place residents at risk of disruption in the continuity of care. Findings include: Record review of CR #1's undated face sheet revealed he was admitted to the facility on [DATE] and discharged from the facility on 03/21/25 with diagnoses of Pulmonary embolism (a blockage in the pulmonary arteries of the lungs), Protein-calorie malnutrition (insufficient intake of protein and calories), acute right heart failure (chronic condition in which the heart does not pump blood as well as it should), and dementia (memory loss). Record review on 06/19/25 of the discharge summary revealed CR…

  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 · E2024-05-23 · tag F0803 — failed to meet residents' dietary needs — pattern
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview the facility failed to ensure the menus were followed for 3 meal services prepared for 36 of 36 residents. The facility failed to ensure the menu was followed for the lunch meals on 5/21/24 and 5/22/24 and the dinner meal on 5/22/24. These failures could place residents at risk for dissatisfaction, poor intake, and/or weight loss. The findings included: Interview on 05/21/24 at 10:20 AM with [NAME] A revealed the kitchen manager is out on medical leave and the manager from another facility comes in a few times a week to order food and check the menu. [NAME] A said she was not aware of any complaints from residents about the food. Observation on 5/21/24 at 11:00 AM of the dining room revealed a posted weekly menu which displayed the following to be served for lunch: Garlic pepper pork loin with gravy, seasoned beans and sautéed squash, cornbread, cream pie. Observation on 5/21/24 at 12:25 PM of lunch meal served to residents was: Baked Ham, diced beets, buttered noodles, dinner roll, cheesecake. Interview on 5/22/24 at 10:50 AM with Administrator…

  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 · D2024-05-23 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews and record reviews, the facility failed to ensure a resident receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding for 1 (Resident #11) of 3 Residents reviewed for gastrostomy tube management. The facility failed to address the redness and dried red drainage around Resident #11's stoma (skin and entrance to the stomach) at the G tube (gastrostomy tube) site (a surgically placed device to give direct access to the stomach for feeding, hydration and medicine). This failure could place residents with G-tubes at risk of pain, infection, decline in health and hospitalization. Findings included: Record review of Resident #11's annual MDS for resident assessment and care screening dated 03/15/2024 revealed she had persistent vegetative state/no discernible consciousness. She had impairment on both sides of upper and lower extremities. She used a wheelchair for mobility, and she was dependent on helpers for all ADLs. She was always incontinent of urine and bowel. Section K, swallowing/nutritional status…

  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

$138,543 in federal fines across 3 penalties.

• $32,819 — penalty dated 2025-12-09
• $54,094 — penalty dated 2024-07-10
• $51,630 — penalty dated 2023-10-05

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 LIFE CARE CENTERS OF AMERICA — 194 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 23 rows in the source record cover these 15 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.

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

Follow the money — this home’s finances

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

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 23% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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.

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