Paradigm at Westbury

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.

34.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 43 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 62.5% 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 24 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 0.33 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 148 beds and averages 103.5 residents a day — about 70% occupied, or roughly 44 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 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 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 3.07 hrs/resident/day on weekends vs 3.52 on weekdays — 13% thinner on weekends. RN hours go from 0.37 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% is well above the national median of 45%. 3 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.

42 citations, most serious first. The 17 most serious are shown; the remaining 25 are one tap away and print in full.

• Immediate jeopardy · Kcited before2025-08-28 · 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 residents who need respiratory care are provided such care consistent with professional standards of practices for 5 of 5 residents (CR # 1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for respiratory care related to tracheostomy care. The facility failed to train nurses on tracheostomy care, including LVN A. On 8/21/2025, LVN A noticed CR #1's trach appeared to be at an angle and when CR # 1 was repositioned, his entire tracheostomy was out and, on his chest below his chin. Attempts to reinsert the tracheostomy canula were unsuccessful as the stoma was closed. CR # 1 was admitted to the hospital with evidence of prolonged decannulation SNF stay. The facility failed to ensure licensed nursing staff were trained to provide tracheostomy care for CR # 1, Resident # 2, Resident # 3, Resident # 4 and Resident # 5 An Immediate Jeopardy (IJ) situation was identified on 8/27/2025. The IJ template was provided to…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2025-01-15 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for three of three resident hallways (B, C, D) and facility common areas reviewed for environment. 1. The facility failed to maintain two working HVAC units to distribute heat to halls B and C. 2. The facility failed to maintain temperatures in Halls B, C and D (rooms 201, 209, 211, 215, 313, 314, 315, 317, and 401) were above 71 degrees Fahrenheit (61-70 degrees Fahrenheit). An Immediate Jeopardy (IJ) was identified on 1/10/2025. The I.J. template was provided to the facility on 1/101/2025 at 5:14 p.m. While the IJ was removed on 1/15/2025, the facility remained out of compliance at a scope of widespread with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems . These deficient practices could place residents at risk…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-02-05 · 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 observations, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 14 residents (Resident #1, Resident #2, and Resident #3) reviewed for smoking. 1. The facility failed to secure smoking paraphernalia and supervise smoking for Resident #1, who was paralyzed on one side and had a known history of dropping cigarettes which resulted in multiple burn holes in his clothing and the armrest of his wheelchair. 2. The facility failed to secure smoking paraphernalia and supervise smoking for Resident #2 and Resident #3, who were known to have unsafe smoking habits and were either prescribed oxygen or had a roommate who was prescribed oxygen. An Immediate Jeopardy (IJ) was identified on 02/03/2024 at 8:33 a.m. The IJ template was provided to the facility on [DATE] at 8:33 a.m. While the IJ was removed on 02/04/2024, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that is…

  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 · K2024-02-05 · tag F0926 — failed to keep the home smoke-free / fire-safe — pattern
  Have policies on smoking.
  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 follow their own established smoking policy for 3 of 14 residents (Resident #1, Resident #2, and Resident #3) reviewed for smoking and compliance. 1. The facility failed to effectively intervene or implement their own smoking policy when Residents #1 was known to be non-compliant and continued to store his own smoking paraphernalia. 2. The facility failed to assess Resident #2 for safe smoking upon admission on [DATE] until 02/02/2024. Resident #2 and Resident #3 did not sign smoking contracts until 02/03/2024. 3. The facility failed to implement their smoking policy and allowed Resident #2, who was prescribed oxygen and Resident #3, whose roommate was prescribed oxygen, to store their own smoking paraphernalia. An Immediate Jeopardy (IJ) was identified on 02/03/2024 at 8:33 a.m. The IJ template was provided to the facility on [DATE] at 8:33 a.m. While the IJ was removed on 02/04/2024, the facility remained out of compliance at a scope…

  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
• Actual harm · G2026-05-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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 acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 2 of 3 residents (Resident #57 and Resident #91) reviewed for nutrition status. The facility failed to identify and verify significant weight loss for Resident #91 who lost 32.4 pounds in 27 days. The facility failed to provide dietary interventions for Resident #91's initially identified weight loss on 5/13/2026 (118.8lbs from 148.6 lbs.), until 5/27/2026. The facility failed to ensure Resident #57 had daily weights obtained per physician order. These failures could place residents at risk for compromised nutrition, decline in function and unplanned weight changes. Findings included: Resident #91 Record review of Resident #91's admission record, dated 05/29/2026, revealed a…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-01-28 · 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 interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (CR#1) of 1 resident reviewed for accidents hazards/supervision. The facility failed to prevent CR#1 from falling from his bed and sustaining a minor head injury on 08/05/24 while CNA A performed a bed bath alone even though the resident required 2-person assist. This failure could place residents at risk of harm, potential accidents, and a diminished quality of life. Findings included: Record review of CR#1's face sheet dated 1/26/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included acute and chronic respiratory failure with hypoxia, cerebral infarction (blood supply to part of the brain that is blocked or reduced), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), history of falling and functional…

  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 · G2024-01-07 · 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 treatment and care in accordance with professional standards of practice was provided to 1 of 8 residents (Resident #83) reviewed for quality of care. The facility failed to check Resident #83's vital signs, including his blood sugar, when he experienced a change in condition on 11/28/23. When emergency personnel arrived, they discovered his blood sugar was 48. Resident #83 was admitted to the hospital for symptomatic hypoglycemia. This failure could place residents at risk of decline in health or hospitalization. Findings included: Record review of Resident #83's face sheet dated 12/14/23 revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included type 2 diabetes, cirrhosis of the liver (severe scarring of the liver that can be caused by many forms of liver diseases and conditions), chronic kidney disease, heart failure, and myocardial infarction (damage to the heart muscle caused by a…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-05-30 · 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 failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 4 (Resident #81, Resident #12, Resident #92 and Resident #101) of 9 residents reviewed for infection control. The facility failed to ensure Resident #81's and Resident #101's urinary catheter bags were not touching or lying on the ground. The facility failed to ensure RN B used a gown when providing enteral feeding to Resident #12 and LVN D used a gown and followed appropriate wound care protocol when providing wound care to Resident # 92. These failures could place residents at risk of infection, decline in health, or cross contamination.Findings included: 1. Record review of Resident #81's face sheet, dated 5/27/26, revealed a [AGE] year-old female admitted on [DATE] with diagnoses including epilepsy (chronic…

  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 · Dcited before2026-05-30 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  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, observation and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for 1 (Resident #41) of 6 residents reviewed for care plan.The facility failed to ensure that Resident #41 was care planned regarding refusal to have a privacy cover on his urinary catheter bag. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of Resident #41's face sheet, dated 5/7/26, revealed a [AGE] year-old male, admitted [DATE], with diagnoses including paraplegia (loss of the ability to move in part or most of the legs and lower body) and obstructive (condition where urine is prevented from flowing normally) and reflux uropathy (condition where urine flows backward into the kidneys).Record review of Resident #41's admission MDS assessment, dated 5/9/26, section C (Cognitive Patterns) revealed a…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-30 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  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 its medication error rate was not 5 percent or greater. The facility had a medication error rate of 12.0% based on 3 errors out of 25 opportunities (Resident #108 and Resident #80) reviewed for medication administration. The facility failed to ensure RN A administered insulin injection at the appropriate site as per physician's order for Resident #108.The facility failed to ensure MA A accurately dispensed and administered oral medication and eye drops as per physician's orders for Resident #80. These failures could place residents at risk for incomplete therapeutic outcomes and decline in health. Findings included: 1. Record review of Resident # 108's face sheet, dated 05/30/2026, revealed a [AGE] year old female admitted [DATE], with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia (inability of the body's cell to respond properly to the hormone insulin), Cerebral Infarction (death of brain tissue cause by…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-30 · 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

  Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 1 (D Hall) of 4 medication aide carts, 2 (B Hall and D Hall) of 4 nurse medication carts and 2 (A Hall and D Hall) of 4 medication storage rooms reviewed for medications storage. -Facility failed to ensure medication aide cart and nurse cart did not have medications that were discontinued. -Facility failed to ensure medication storage room did not have any items stored under the sink. These failures could place residents at risk for drug diversion and contamination of supplies placed under the sink. Findings included: During an observation on 5/27/2026 at 2:15pm, D hall medication aide cart revealed the following medications: Quetiapine 25mg - pharmacy issue date 3/28/2026 with remaining 9 pills for Resident # 74, Potassium Chloride Liquid 10% - pharmacy issue date 12/8/2025, give 15ml in the evening for 5 days for Resident # 64 and Amlodipine 2.5mg give 1 tab daily - pharmacy…

  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 · D2026-05-30 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  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's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 2 of 9 residents reviewed for immunizations. (Resident #2 and Resident #115)The facility failed to document, in Resident #2's and Resident #115's medical records, having had received education, whether by self or with responsible party, of the benefits and potential side effects of the influenza immunization and receipt of the of the pneumococcal immunization or having had not received the pneumococcal immunization due to medical contraindication or refusal.This failure could place residents at risk of contracting a viral illness, influenza and pneumococcal,…

  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 · D2026-05-30 · tag F0887 — isolated
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review , the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 2 of 9 residents who were reviewed for immunizations. (Resident #2 and Resident #115) The facility failed to document, in Resident #2's and Resident #115's medical records, having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal.This failure could place residents at risk of not being informed of complications and potential adverse health outcomes.Findings included: 1. Record review of Resident…

  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 · Dcited before2025-11-24 · 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 observation, 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 (Resident #1) of 3 residents reviewed for resident rights. This failure could affect the resident who required assistance with her Activities of Daily Living (ADL) from facility staff by placing them at risk for social isolation, loss of dignity, and self-worth. - The facility failed to ensure Resident #1 was provided with personal grooming (changed brief and clean clothing) before her discharge to the hospital on [DATE]. This failure placed residents at risk for embarrassment, at risk of loss of dignity and a decrease in quality of life.The findings include: Record review of Resident #1's Face Sheet dated 10/17/2025 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 10/17/2025. Resident #1…

  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 · Dcited before2025-11-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 3 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1 was provided with personal grooming before her discharged to the hospital on [DATE]. This failure could place residents at risk for discomfort and dignity issues.Findings included: Record review of Resident #1's Face Sheet dated 10/17/2025 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 10/17/2025. Resident #1 had diagnoses included: Acute kidney failure (condition where the kidneys suddenly lose their ability to filter waste products from the blood), contusion (bruising) of right lower leg, End stage renal disease (inadequate kidneys function), hypertensive heart and chronic kidney disease without heart failure (damages the heart…

  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 before2025-05-02 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment, for daily living for residents living on 1 of 4 halls (Hall D) reviewed for resident rights in that: 1. Four rooms on Hall D (westside of building) had room temperatures of more than 81 degrees Fahrenheit (rooms 404, 405, 406, and 407). This failure could have caused hyperthermia, hospitalization, and a diminished quality of life. Findings Included: Hall D Observation of Rooms #404, 405, 406, and 407 on 5/1/2025 at 10:34 a.m. had the following room temperatures: room [ROOM NUMBER] -temperature was 84.0 degrees Fahrenheit. room [ROOM NUMBER]- temperature was 82.4 degrees Fahrenheit. room [ROOM NUMBER]- temperature was 82.2 degrees Fahrenheit. room [ROOM NUMBER]- temperature was 81.5 degrees Fahrenheit. Observation on 5/1/2025 at 10:34am of the wall thermostat located between room [ROOM NUMBER] and #404 had a temperature of 86 degrees. Observation on 5/1/2025 at 10:42am revealed a…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-28 · 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 each resident. -MA J would have administered the incorrect dosage if not for Surveyor intervention. -Five medications for Resident #66 were not available. -The facility failed to ensure Midodrine (a blood pressure (BP) medication given to elevate hypotension (low blood pressure) was administered 17 times in March to Resident #96 as ordered on 12/01/2024 by the physician. -The facility failed to ensure Resident #72 was not administered insulin outside of the parameters. These failures could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health. Findings included: Resident #66 Record review of the admission Record for Resident #66 revealed he was [AGE] years old and was 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.

  Pharmacy Service Deficiencies · Deficient, Provider has plan 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

$108,038 in federal fines across 4 penalties.

• $26,180 — penalty dated 2026-05-30
• $14,596 — penalty dated 2025-08-28
• $52,699 — penalty dated 2025-01-15
• $14,563 — penalty dated 2024-01-07

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 PARADIGM HEALTHCARE — 17 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 14 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

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