Misty Willow Healthcare 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.

51.9% 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 79 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 65.0% 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 20 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 1.20 therapist hours per resident per day in 2026Q1 — more than 98% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 124 beds and averages 89.8 residents a day — about 72% occupied, or roughly 34 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 3.30 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 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 2.87 hrs/resident/day on weekends vs 3.47 on weekdays — 17% thinner on weekends. RN hours go from 0.38 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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.

30 citations, most serious first. The 18 most serious are shown; the remaining 12 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-03-09 · 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 interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on the resident's comprehensive assessment for 1 closed record (CR #1) and 3 of 3 residents reviewed for quality of care.The facility failed to seek medical guidance or report a fall that resulted in injury, including pain, swelling and a broken femur, to CR #1 for approximately 3-days.The facility nurse failed to assess CR #1 after a fall. On 03/06/2026 at 06:38 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 03/08/2026 12:46 p.m. the facility remained out of compliance at a scope of isolation and a severity of harm with potential for more than the minimal harm that was not an immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.These failures could place residents at risk or…

  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 · K2025-09-24 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure each resident was free from abuse for 2 of 17 residents (CR #2, Resident #5) reviewed for abuse in that: 1. CR #1 sexually abused Resident #5 on 4/19/25 when he touched her breast.2. CR #1 sexually abused an unknown female resident on 5/21/25 when he touched her thigh.3. CR #1 sexually abuse CR #2 on 7/14/25 when he touched her breast and on 8/3/25 when he touched her breast and in between her thighs. An IJ was identified on 9/19/25. The IJ template was provided to the facility on 9/19/25 at 4:52pm. While the IJ was removed on 9/21/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems. These failures placed residents, who resided in the facility, at risk of abuse, and mental anguish and fearfulness. 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-09-24 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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 implement written policies and procedures that prohibit and prevent abuse for 2 of 17 residents (CR #2, Resident #5) reviewed for abuse. The facility failed to implement written policies regarding abuse prevention and protection when CR #1 sexually abused Resident #5, an unidentified female resident, and CR #2 within a 4-month period between 4/19/25 and 8/3/25. The facility failed to ensure LVN B and CNA A, with knowledge of an allegation of sexual abuse on 5/21/25, reported the abuse immediately to the Administrator. An IJ was identified on 9/19/25. The IJ template was provided to the facility on 9/19/25 at 4:52pm. While the IJ was removed on 9/21/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems. These…

  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
• Immediate jeopardy · K2025-09-24 · tag F0610 — failed to investigate and act on abuse reports — pattern
  Respond appropriately to all alleged violations.
  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 have evidence that all alleged violations of sexual abuse were thoroughly investigated for 2 of 17 residents (CR #2, Resident #5) reviewed for abuse. The facility failed to take steps to prevent further potential abuse and take appropriate corrective action as a result of investigation findings when CR #1 sexually abused CR #2, an unidentified female resident and Resident #5 within a 4-month period between 4/19/25 and 8/3/25. An IJ was identified on 9/19/25. The IJ template was provided to the facility on 9/19/25 at 4:52pm. While the IJ was removed on 9/21/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems. These failures placed residents, who resided in the facility, at risk of abuse, and mental anguish 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-09-24 · 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 observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's nursing, mental and psychosocial needs for 1 of 17 residents (CR #1) reviewed for comprehensive care plans in that: CR #1's care plan was not revised when he sexually abused Resident #5, an unidentified resident and CR #2 and had one sexual inappropriate behavior within a 4-month period between 4/19/25 and 8/3/25. Nursing staff, including LVN B, CNA A, LVN C, CNA B, LVN D and CNA C, were unaware of interventions for CR #1 that would prevent further sexual abuse from occurring. An IJ was identified on 9/19/25. The IJ template was provided to the facility on 9/19/25 at 4:52pm. While the IJ was removed on 9/21/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy as…

  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 before2025-03-29 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure residents were receiving person-centered Quality of Care for 1 residents (CR#1 ) of 8 residents reviewed. The facility failed to ensure CR #1 was properly transferred from the floor to the bed when displaying signs/symptoms of a fracture (pain, deformity, etc). CR #1 sustained a hip fracture. The facility failed to acknowledge CR#1's verbal complaint of pain by picking her up off the floor possibly causing more harm. The facility failed to follow physician orders and administer CR #1's pain medication (PRN). This failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:34 p.m. While the IJ was removed on [DATE] at 7:22pm, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal…

  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 before2025-03-29 · 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 interviews, and record review, the facility failed to ensure residents were free from Accident Hazards and Supervision for 1 resident (CR#1) of 8 residents reviewed for Accident Hazards and Supervision. The facility failed to ensure each CR #1 was transferred properly after she was found face down on the floor, sustaining multiple injuries, including laceration above the eye, closed head injury and broken femur. The facility failed to acknowledge CR#1's verbal complaint of pain by picking her up off the floor possibly causing more harm. An Immediate Jeopardy (IJ) was identified on 03/27/2025 at 4:34 p.m. While the IJ was removed on 03/29/2025 at 3:30pm, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of physical harm. Findings Include: 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
• Immediate jeopardy · Jcited before2025-03-29 · 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 interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for CR#1 & CR#2 of 8 residents reviewed for pharmacy services. The facility failed to ensure CR #1 received his medication as ordered when WCN administered non-scheduled aspirin without an order when CR #1 had a known head injury. The facility failed to ensure CR#2 recevied his IV antibiotic medication as ordered by the physician. An Immediate Jeopardy (IJ) was identified on 03.27.25 at 4:34 p.m. While the IJ was lowered on 03.29.25 at 3:30pm, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of receiving inadequate…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-09 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 closed record (CR #1) of 4 residents reviewed for resident rights. The facility failed to follow their fall protocols and ensured CR #1 received a nursing assessment. This failure could affect the residents who require assistance with their ADLs from facility staff by placing them at risk for social isolation, loss of dignity, and self-worth. The findings included: Record review of CR #1's face sheet dated 05/21/2025 reflected CR #1 was a [AGE] year-old female who admitted to the facility on [DATE] and discharged on 02/16/2025. CR #1's diagnosis of unspecified fall, hemiplegia and hemiparesis (neurological conditions causing motor impairment on one side of the body due to brain injury) following cerebral infarction (stroke: issue death (necrosis)…

  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 · F2025-12-04 · 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, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. The facility failed to ensure food was properly stored, labeled, and dated in the walk-in refrigerator, walk-in freezer, and dry goods pantry. The facility failed to ensure dietary staff used facial hair restraints while in the kitchen properly while food was actively being prepared. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings Include: Observation of the walk-in refrigerator on 12/02/2025 at 8:47 AM revealed:1. One open box on bottom shelf exposing raw, in-shell eggs on trays undated2. One open box on 4th shelf down of bulk raw bacon in an open plastic bag exposed to air, no open date on box3. One bag on 2nd shelf down of sliced potatoes was open and top loosely folded over not secured, no dates on bag Observation of the walk-in freezer 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-04 · tag F0805 — failed to prepare food in a form residents can eat — pattern
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  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 food was prepared in a form designed to meet individual needs for 3 of 3 meals observed (lunches on 12/02/2025, 12/03/2025, and 12/04/2025) and reviewed for proper textures. The facility failed to ensure that mechanical soft foods were served at the proper texture on 12/02/2025, 12/03/2025, and 12/05/2025. This failure could affect all residents on mechanical soft texture diets by placing them at risk for choking and weight loss.Findings Included: Observation of meal service on 12/02/2025 at 12:20 PM revealed [NAME] F plating a mechanical soft meal of chicken enchiladas, Spanish rice, and refried beans. [NAME] F quickly hand-chopped the enchilada in the pan with the serving spatula before plating. The chicken in the enchiladas was originally sliced. There was no check to ensure the chicken or tortilla pieces were adequate in size for a mechanical soft diet. Observation of lunch test trays of regular texture and mechanical soft texture on 12/03/2025 at 12:10 PM revealed boneless pork chop with gravy,…

  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 · E2025-12-04 · tag F0813 — pattern
  Have a policy regarding use and storage of foods brought to residents by family and other visitors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 3 (Residents #45, #73, and #89) of 8 residents reviewed for refrigerators in the rooms. The facility failed to monitor temperatures and did not put thermometers in Residents #45, #73, and #89's refrigerators. These failures could affect residents by placing them at risk for food-borne illnesses. Finding included: Resident #89Record review of Resident # 89's face sheet, dated 12/02/25, revealed she was a [AGE] year-old female with an original admission date of 01/28/22 and readmitted to the facility on [DATE]. Her primary diagnosis was cerebral infraction due to embolism of the middle cerebral artery (this is a stroke caused by a blood clot in the brain). Record review of Resident #89's care plan initiated on 01/27/24 revealed Resident #89 had occasional nausea and vomiting. The…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that resident's environment remained as free of accident hazards as was possible, and each resident received adequate supervision and assistance devices to prevent accidents for 2 (Residents #21 and #47) of 15 residents reviewed for accidents. The facility failed to ensure Residents #21 and #47 had an environment free of accident and hazards by not providing a safe shower chair that had wobbly, loose, unsteady legs. This failure affected residents by placing them at risk of slipping and falling while taking a shower. Findings include: Record review of Resident #21's Face Sheet dated 12-4-2025 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #21 had a primary diagnosis of acute on chronic systolic congestive heart failure (a condition where the ventricle struggles to pump effectively. It signifies a sudden worsening of long-standing heart weakness (systolic failure) where the heart can't pump…

  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 · D2025-12-04 · tag F0694 — isolated
  Provide for the safe, appropriate administration of IV fluids 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 Number of residents sampled: Number of residents cited: Based on observation, interviews, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 (Resident #25) residents reviewed for peripheral intravenous care. The facility failed to ensure physician orders for Resident #25 were followed to change PICC (PICC line is a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) line dressing changes every 7 days as ordered. This failure could affect residents by placing them at risk of infection. Findings included: Record review of Resident #25's face sheet dated 12/02/25 indicated Resident #25 was a [AGE] year-old female with an initial admission on [DATE] and readmitted to the facility on [DATE] with a primary diagnosis of other acute osteomyelitis Right ankle and foot (this is an active bone infection in the ankle and foot). 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 before2025-12-04 · 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 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 one of five residents (Resident#71) reviewed for medication administration of insulin. LVN C failed to clean and disinfect Resident #71's skin before administering Insulin on his upper right arm on 12/02/25. This failure affected the residents by placing them at an increased and unnecessary risk of exposure to infections. Findings included: Record review of Resident #71's face sheet dated 12/02/25, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included malignant neoplasm of prostate (this is Cancer of the prostate), cerebral infarction (stroke), and diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified (this is uncontrolled blood sugars diseases with nerve pain). Record review…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-04 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of five residents (Resident #92) reviewed for storage of medication. LVN B failed to ensure Pregabalin (control drug), Levetiracetam [seizure medication], Baclofen [pain medication] and multi vitamins were not stored at Resident #92's bedside table and failed to ensure it was secured in the medication cart or medication room when she was not at the bedside on 12/03/25. This failure could place residents at risk of medication misuse and accidental ingestion. The findings include: Record review of Resident #92's face sheet dated 12/03/25 revealed a [AGE] year-old female with an initial admission to the facility on [DATE] and was readmitted on [DATE] with a primary diagnosis of unspecified multiple sclerosis (this is an immune…

  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 · D2025-09-24 · tag F0564 — isolated
  Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
  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 inform each resident of his or her visitation rights and related facility policy and procedures, including any safety restrictions or limitation on such rights, the reason for the restriction or limitation, and to whom the restrictions apply for 1 of 17 residents (Resident #2) reviewed for resident rights. Resident #2 was not informed by the facility when her family member was no longer allowed to visit due to safety restrictions after February 2025. This failure placed residents at risk of not being informed of their rights, confusion and sadness. The findings included: Record review of Resident #2's admission Record generated on 9/23/25 revealed she was admitted to the facility on [DATE]. She had diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), adjustment disorder (a mental disorder defined by maladaptive response to a psychosocial stressor) and depression (a mental health disorder characterized…

  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 · E2024-08-30 · 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 did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 Staff (CNA W) reviewed for infection control. - The facility failed to ensure CNA W followed proper hand hygiene during incontinent . - The Wound Care Nurse did not practice hand hygiene before and after wound care for Resident #20. These deficient practices could affect residents and place them at risk for infection, and reinfection. Findings include: Record review of Resident # 10's annual MDS assessment, dated 07/15/24, reflected a [AGE] year-old female with an admission date of 07/15/21. Her diagnoses included urinary tract infection, cerebrovascular disease ( stroke, brain aneurysms and cerebral arteriovenous/blood clots), muscle wasting and atrophy, stage 4, type 2 diabetes mellitus (a chronic disease that occurs when the body…

  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

“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

$79,412 in federal fines across 3 penalties.

• $43,770 — penalty dated 2026-03-09
• $20,495 — penalty dated 2025-09-24
• $15,147 — penalty dated 2025-03-29

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

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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 $1.0M 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