Memorial City Nursing and Rehabilitation Center

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.

49.4% 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 130 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 64.2% 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 53 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 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 29% 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 187 beds and averages 135.1 residents a day — about 72% occupied, or roughly 52 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 3.20 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.22 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 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 2.82 hrs/resident/day on weekends vs 3.35 on weekdays — 16% thinner on weekends. RN hours go from 0.25 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% 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.

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

• Immediate jeopardy · K2024-09-23 · 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 observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 1 (Resident #1) of 3 residents reviewed for care plans in that: The facility failed to ensure Resident #1 bed was in the lowest position per care plan while he was in the bed. The facility failed to update falls and interventions for Resident #1's care plan after his last 3 falls. This failure placed facility residents who were fall risk at risk of serious harm and injury. An Immediate Jeopardy (IJ) was identified on 9/18/2024. The IJ template was provided to the Administrator In-Training and DON on 9/18/2024 at 12:46 p.m. While the IJ was removed on 9/20/2024 at 12:30 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of…

  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 · K2024-09-23 · 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 each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for free of accidents, hazards, supervision, and devices., in that: The facility failed to ensure precautionary interventions in place Resident #1, while he was prescribed an anticoagulant, who was a known fall risk that resulted in falls with injuries to the head and hospitalization. An IJ was identified on 9/17/2024. The IJ template was provided to the AIT and DON on 9/17/2024 at 5:06 p.m. While the IJ was removed on 9/20/2021 at 12:31 p.m., with the ADMIN and DON. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility staff had not been trained on identifying residents at risk for fall, preventions, and interventions, and modification and care plan falls. This…

  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 · G2026-04-28 · 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 interview, and record review, the facility failed to ensure resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 13 residents (Resident #21) reviewed for abuse. The facility failed to ensure Resident #21 remained free from abuse when LVN A removed the resident's property (cell phone) as a way to restrict the resident's communication (preventing calls to 911). These failures could place residents at risk of an unsafe environment and unprotected from mistreatment. The findings included: Record review of Resident #21's face sheet dated 04/23/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included systemic lupus erythematosus (a chronic, autoimmune disease where the immune system attacks healthy tissues, causing widespread inflammation and damage to organs), unspecified, epilepsy (chronic brain disorder characterized by recurrent, unprovoked seizures caused by electrical…

  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 · G2026-04-28 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to ensure that pain management was provided to Resident #21's who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility failed to monitor and address Resident #21's pain on 03/04/2026 from 3:00 a.m. to 11:00 a.m., when Resident #21 pressed her call light, cried out in pain, called 911 twice, and pulled the fire alarm requesting to go to the hospital. This failure had the potential to place residents at risk for delayed treatment, pain, and actual harm. The findings included: Record review of Resident #21's face sheet dated 04/23/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included systemic lupus erythematosus, epilepsy, anxiety disorder, obesity, pain in unspecified joint, stiffness of unspecified joint, muscle wasting and atrophy, cognitive communication deficit,…

  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 · G2025-01-15 · 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 observation, interviews, and record review the facility failed to ensure based on the comprehensive assessment of a resident, residents received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (CR#1) of five residents reviewed for pressure ulcers . The facility failed to ensure CR #1 did not acquire an unstageable pressure ulcer to her bilateral buttock. This failure could place residents at risk for developing pressure wounds, Cellulitis (skin infection), Sepsis (infection of the blood) and severe pain. Findings included: Record review of CR#1's face sheet dated 01/11/2025, reflected a [AGE] year-old female initially admitted 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-19 · 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 interviews and record review, the facility failed to ensure residents requiring respiratory care, consistent with professional standards of practice for 1 (CR#1) of 5 residents reviewed for quality of care.The facility failed to provide immediate care to CR#1 when she experienced respiratory distress on 05/08/24. After the resident was observed gurgling with emesis by LVN A, the NP was notified; monitoring nor interventions were initiated. When observed by the NP, CR #1 was unresponsive and oxygen saturation dropped to 60%. 911 was called and arrived at 12pm. During the course of hospitalization, CR #1 was declared brain dead and expired on 05/13/24 after atifical support was removed.This failure placed residents who developed a change in respiratory status at risk of physical harm, emotional distress, mental anguish, and hospitalization or death from possible neglect.Finding included:Record review of the admission sheet (undated) for CR#1 revealed a [AGE] year-old female admitted 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
• Potential for harm · F2026-04-28 · tag F0887 — widespread
  Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record reviews and interviews, the facility failed to ensure each resident is offered the COVID-19 (infectious respiratory illness caused by the corona virus) vaccine unless the immunization is medically contraindicated, or the resident has already been immunized for all residents.The facility failed to offer COVID vaccine to its residents upon admission to the facility. This failure could place residents at risk of COVID. The findings are: During an interview on 04/24/2026 at 10:13 a.m., the ICPN stated the facility did not offer COVID vaccines to its residents. She stated residents and residents' representatives always declined the COVID vaccination, so the facility stopped offering the vaccine. She stated she was unaware the facility should have offered the vaccine to its residents and they could accept or refuse to receive it. She stated she did not recall when the facility stopped offering the vaccine to its residents. She stated if the facility did not offer the vaccine to residents, they could be at a higher risk of COVID disease. During an interview on 04/24/2026 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-28 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  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 observation, interview and record reviews, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 8 residents (Resident #38) reviewed for call light placement. The facility failed to ensure Resident #38's call light was within reach on 04/24/2026, while he was lying in bed. These failures could place residents at risk of not receiving immediate assistance when needed. Findings include: Record review of Resident #38's Face Sheet, dated 04/24/2026, reflected, a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included cerebral infarction (when blood flow to part of the brain is blocked), muscle weakness and history of falling. Record review of Resident #38's admission MDS (a standardized, mandatory assessment tool used by nursing homes to evaluate…

  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 · D2026-04-28 · tag F0628 — isolated
  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 ensure that a written notice of transfer or discharge, was provided to the resident and/or their representative contained all federally mandated elements for 1 of 4 residents (Resident #40) reviewed for discharge notices. The facility failed to ensure that Resident #40's written notice of transfer or discharge, including a safe discharge location. The facility failed to ensure that Resident #40's written notice of transfer or discharge, contained the Ombudsman's name and email address. These failures could place the residents at significant risk by bypassing critical safeguards meant to ensure their safety and continuity of care.Findings included: Record review of Resident #40's face sheet dated 04/26/2026, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included, lesion of radial (dysfunction in the arm, leading to symptoms like wrist drop, weak triceps, and numbness on the back of 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
• Potential for harm · D2026-04-28 · 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 interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the Center for Medicaid/Medicare System (CMS) System for 1 of 6 closed records (CR #154) reviewed for Minimum Data Set (MDS) transmission. - The facility failed to complete and retransmit CR #154's MDS discharge assessment within 14-days of CR #154's discharge when the anticipated return had not resulted in a readmission. This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required. The findings were: Record review of CR #154's face sheet dated 04/23/2026, reflected, CR admitted to the facility on [DATE] and discharged on 01/23/2026. CR's had diagnoses which included pain in right shoulder, unspecified fall, pain in unspecified joint, muscle wasting and atrophy, multiple sites, cognitive communication deficit, need: assistance with personal care, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood…

  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 before2026-04-28 · 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

  Based on observations, interviews 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 2 of 10 residents (Resident #30, Resident #41) reviewed for medication storage and labeling.The facility failed to ensure nurses dated Residents #30 and 41's opened insulin glargine (a medication prescribed to help the body manage blood sugar levels) pens and discarded them within 28 days of opening, on 04/24/2026.This failure could place residents at risk of receiving medications that were less effective or expired and the risk of contamination or chemical degradation (change of a substance into something else, often making it weaker, useless, or harmful).Findings included: Record review of Resident #30's Provider Orders dated 04/09/2026, revealed an active order to receive insulin glargine 100 units/ml multiple-dose pen. Inject 20 units SQ (under the skin) one time a day for diabetes (a disease in which 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 · E2025-11-19 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  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 residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for 3 out of 8 residents (Resident #22, Resident #17, and Resident #24) reviewed for ADLs.1. The facility failed to provide scheduled showers and/or bed baths on M/W/F to Resident #22 on 9/17/25, 9/19/25, 9/22/25, 9/26/25, 10/1/25, 10/3/25, 10/6/25, 10/8/25, 10/10/25, 10/13/25, and 10/15/25.2. The facility failed to provide scheduled showers and/or bed baths on M/W/F to Resident #17 on 9/17/25, 9/19/25, 9/22/25, 9/24/25, 9/26/25, 9/29/25, 10/1/25, 10/3/25, 10/6/25, 10/8/25, and 10/10/25.3. The facility failed to provide scheduled showers and/or bed baths on M/W/F to Resident #24 on 9/17/25, 9/19/25, 9/22/25, 9/24/25, 9/26/25, 10/1/25, 10/3/25, 10/6/25, 10/8/25, 10/10/25, 10/13/25, and 10/15/25.This failure could place residents at risk of skin breakdown, infection, and reduced feelings 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
• Potential for harm · D2025-11-19 · tag F0919 — failed to provide a working call system — isolated
  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 adequately equip to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 (Residents #35) of 6 residents reviewed for call lights.-Residents #35 did not have her call light within reach while she was in bed.This failure could lead to residents not being able to request and receive prompt medical care and result in injury and harm.Record review of Resident #35's face sheet dated 10/16/2025, she was a [AGE] year-old female originally admitted on [DATE] with medical diagnoses including vascular dementia, bipolar disorder, generalized anxiety disorder, Alzheimer's Disease, hypertension, cognitive communication deficit and other abnormalities of gait and mobility.Record review of Resident #35's Quarterly MDS assessment dated [DATE], she had a BIMS score of 3 out of 15, indicating severe cognitive deficit…

  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 · Ecited before2025-07-01 · 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 During observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for the 300 and 400 halls, in that: The facility continues had an infestation of roaches in Residents' rooms as observed in the following: 317,321,323, 327 and 405. This failure could expose Residents to infection and decreased quality of life. During observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for the 300 and 400 halls, in that: The facility continues had an infestation of roaches in Residents' rooms as observed in the following: 317,321,323, 327 and 405. This failure could expose Residents to infection and decreased quality of life. Facility's record review shows, Resident # 4 was a [AGE] year-old male who was admitted to the facility on [DATE]. He was admitted with the following diagnoses: Cerebral infarction unspecified, Type 2 diabetes, Morbid…

  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 · Ecited before2025-02-13 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  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 observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 5 (Residents #21 #22, #44, #51 and #108) of 16 residents reviewed for cleanliness and sanitization. 1. The facility failed to address damaged and unclean walls in Residents #22, #44, and 51's room. 2. Resident #21's headboard was loose and moving back and forth. 3. Resident #108's wash basin on the nightstand that was not labeled and there was another wash pan in the bathroom that was not labeled or bagged. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. The findings include: Observation on 2/11/2025 at 9:41am in Resident #51's room revealed the wall at the head of bed had missing paint. Observation on 2/11/2025 at 10:07am in Resident #44's room revealed the room had a hole in the…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-02-13 · 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 needing respiratory care, including tracheostomy care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 6 of 8 (Residents #14, #21, #11, #17, #43 and #86) reviewed for oxygen. Resident #14's continuous oxygen was observed set at 8L/min on 02/11/2025 when he had a physician order for continuous oxygen at 6L/min. Resident #21's nebulizer machine was on the floor on the left side of his bed. The resident had respiratory tubing that was attached to a mask hanging on wheelchair at the bedside. Resident #11's nebulizer tubing and mask was not dated and placed inside of plastic bag when not in use. Resident #17's oxygen tubing was lying on the floor and nebulizer tubing and mask was not dated and placed inside of plastic bag when not in use. Resident #43's and #86's oxygen (O2) tubing was not stored off the floor…

  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

$72,593 in federal fines across 4 penalties.

• $11,340 — penalty dated 2026-04-28
• $21,057 — penalty dated 2025-01-15
• $22,376 — penalty dated 2024-09-23
• $17,820 — penalty dated 2024-05-19

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 WELLSENTIAL HEALTH — 67 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 37 rows in the source record cover these 27 parties — each is shown once here with every role it holds. Nothing is omitted.

11 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.

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