Park Manor of Westchase

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.

48.6% 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 51 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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 125 beds and averages 104.8 residents a day — about 84% occupied, or roughly 20 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 3.25 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 3.02 hrs/resident/day on weekends vs 3.35 on weekdays — 10% thinner on weekends. RN hours go from 0.36 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

32 citations, most serious first. The 17 most serious are shown; the remaining 15 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-02-09 · 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 reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (CR #1) reviewed for supervision.The facility failed to provide sufficient supervision to CR#l on 01/31/2026 at 8:00pm, he was located at approximately 7:00 AM on 02/01/2026, approximately 7 miles from the facility, in the parking lot of a local Emergency Care Center. Upon discovery, CR #1 had sustained a laceration to his right eye, suspected to be from a fall. CR #1 required hospitalization from 02/01/2026 through 02/02/2026.These failures could result in residents not receiving appropriate supervision leading to elopement, injuries, hospitalization, or death.The noncompliance was identified as PNC. The noncompliance began on 01/31/2026 and ended on 02/02/2026. The facility had corrected the noncompliance before the survey began. Record review of CR #1 Facesheet revealed a [AGE] year-old male, was admitted on [DATE] with diagnoses including vascular…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2025-02-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 out of 23 residents (CR #1) reviewed for adequate supervision. -CR #1 left the faciity on [DATE] on pass and did not return. The facility did not know where he was and did not make attempts to locate CR#1. This deficiency exposed residents living in the facility to potential harm, injury or death due to not being adequately monitored. An Immediate Jeopardy (IJ) was identified on 02/21/2025. The IJ template was provided to the facility on [DATE] at 11:13am. While the IJ was removed on 02/21/2025 at 1:40pm with the Administrator, DON, and Regional VP of Operations. While the IJ was lowered, 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 is not an immediate jeopardy because all staff…

  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 · K2023-09-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility failed to ensure residents received treatment and care in accordance with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing for three (CR #1, Resident #2, and Resident #3) of three residents reviewed for treatment of pressure ulcer. The facility failed to ensure CR #1, Resident #2, and Resident #3, received treatment and care in accordance with professional standards of practice, The facility failed to provide daily wound care for CR #1, Resident #2, and Resident #3, resulting in re-infection of wounds, hospitalization, and amputation of CR #1's right foot. Wounds were getting infected and some of the pressure ulcers increased in size and not improving. The facility failed to follow physician orders and treat pressure wounds daily for CR#1 Residents #2 and Resident #3, for multiple days. The facility failed to document wound care provided to CR #1, Resident #2, and Resident #3 on multiple…

  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 · J2023-09-01 · 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 the resident's right to be free from neglect for 1 of 20 residents (CR #1) reviewed for neglect. - The facility failed to ensure CR #1 had adequate supervision to prevent an accident on [DATE] which resulted in a fall with major injury (left femur fracture) requiring surgery on [DATE]. CR #1 passed away on [DATE] after being released back to the facility from the hospital. The facility failed to read and notify the NP accurately of X-Ray results of CR #1's impression of left femur fracture. - The facility failed to update CR #1's care plan and put interventions in place after continued falls. The facility failed to adequately educate staff on caring for residents with high risk for fall. - An Immediate Jeopardy (IJ) was identified on [DATE] at 5:23 PM. While the IJ was removed on [DATE] at 4:53 PM, the facility remained out of compliance at a scope of isolated and severity of actual harm with potential for more than minimal harm that is not…

  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 · J2023-09-01 · tag F0607 — failed to have anti-abuse policies — isolated
  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 interview and record review, the facility failed to implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 20 residents CR #1(Closed Record) reviewed for abuse and neglect policies. The facility failed to ensure CR #1 had adequate supervision to prevent an accident which resulted in a fall with major injury (left femur fracture) requiring surgery on [DATE]. The facility failed to read and notify the NP accurately of X-Ray results of CR #1's impression of left femur fracture resulting in delayed treatment. The facility failed to update CR #1's care plan and put interventions in place after continued falls, An Immediate Jeopardy (IJ) was identified on [DATE] at 5:23 PM. While the IJ was removed on [DATE] at 4:53 PM, the facility remained out of compliance at a scope of isolated and severity of actual harm with potential for more than minimal harm that is not immediate jeopardy, CR #1 sustained serious injury and passed away due to the facility's…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-09-01 · 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 ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 20 residents (CR #1 (Closed Record)) reviewed for free of accidents, hazards, supervision, and devices., in that: The facility failed to ensure CR #1 had adequate supervision to prevent an accident on [DATE] which resulted in a fall with major injury (left sub-capital femoral neck fracture that resulted to him having surgery) on [DATE]. CR #1 declined and passed away on [DATE] after being released back to the facility from the hospital. The Facility failed to implement interventions after each incident of fall for CR #1 on, [DATE], [DATE] and [DATE], An Immediate Jeopardy (IJ) was identified on [DATE] at 5:23 PM. While the IJ was removed on [DATE] at 4:53 PM, the facility remained out of compliance at a scope of isolated and severity of actual harm with potential for more than minimal harm that is not immediate jeopardy, CR #1 sustained servious…

  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 · G2023-09-01 · tag F0777 — isolated
  Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
  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 promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician order for 1 (CR #1) of 20 residents reviewed for radiology services in that: -The facility failed to report CR#1's ( Closed Record) x-ray results of a fracture of the left hip, femur, in a prompt manner. CR #1 fell on [DATE] at 2:00 PM, X-Ray done and NP got result on [DATE] and CR #1 transferred to hospital at 1:13 PM on [DATE] - CR #1 had a hip fracture that had delayed treatment which caused harm to the resident. This failure has the potential to place residents who receive diagnostic testing for delayed treatment and hospitalizations. Findings: Record review of CR #1 of face sheet revealed [AGE] year-old male, date of admission was [DATE] readmission 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-13 · tag F0627 — isolated
  Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Purpose: P1 Complaint Investigation Date: 6/2/2026 Intake: 1093120 [3030810] Census: 99 Abbreviations:Admin-AdministratorADL-Activities Daily LivingBIMS-Brief Interview for Mental StatusBOM-Business Office ManagerCNA-Certified Nurse AssistantC/O-Complaints OfCR-Closed RecordCVA-Cerebral Vascular AccidentDME-Durable Medical EquipmentDON- Director of NursingDX-DiagnosisFM-Family MemberHHC-Home Health CareHO-History OfHTN-HypertensionHX-HistoryIDT-Interdisciplinary TeamLTC-Long Term CareLVN - Licensed Vocational NurseMD-Medical DoctorMDS- Minimum Data SetNOMNC-Notice of Medicare Non-CoverageNP-Nurse PractitionerOT-occupational TherapyPCC-Point Click CarePCP-Primary Care PhysicianPRN- Pro Re NataPT-Physical TherapyROM- Range of MotionR/T-Related ToS/S-Signs and SymptomsSW-Social WorkerTrans-TransportationWC-WheelchairBased on record review and interviews, the facility failed to provide and document sufficient preparation and orientation to residents to ensure a safe and orderly transfer or discharge from 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 · E2026-04-09 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 2 of 12 residents (Resident #6 and #107) reviewed for call light placement.The facility failed to ensure Resident #6's call light was within reach on 04/07/2026, while he was asleep in bed.The facility failed to ensure Resident #107's call light was within reach on 04/07/2026 and 04/08/2026, while he was lying in bed.These failures could place residents at risk of not receiving immediate assistance when needed.Findings include: 1. Record review of Resident #6's face sheet, dated 04/08/2026, reflected, a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included acute osteomyelitis (serous infection of the bone marrow), right ankle and foot, dementia (decline…

  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 before2026-04-09 · tag F0640 — pattern
  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 ensure withing 14-days the facility completed a resident assessment, and electronically transmitted encoded, accurate, and complete MDS data to the CMS System for 2 of 5 closed records (CR #10 and CR #25) reviewed for MDS transmission. The facility failed to ensure CR #10's admission MDS assessment was completed and transmitted within 14 days of CR's entry. The facility failed to ensure CR #25's admission MDS assessment was completed and transmitted within 14 days of CR's admission. Thess failures 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 #10's face sheet dated 04/09/2026, reflected, a [AGE] year-old male who was admitted to the facility on [DATE], readmitted to the facility on [DATE] and 11/02/2025, and discharged on 11/12/2025. CR #10's diagnoses included acute on chronic combined systolic/ diastolic (heart failure) (congestive), end stage…

  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 · Ecited before2026-04-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 2 of 8 (Resident #21 and Resident #33) resident rooms reviewed for accident hazards. The facility failed to ensure mouthwash, hand sanitizer, lotion, hair products and bath wash were properly stored and not out in the open in Resident #21's room on 04/07/2026, 04/08/2026, and 04/09/2026. The facility failed to ensure mouth wash, lotion and hair products were properly stored and not out in the open in Resident #33's room on 04/07/2026, 04/08/2026, and 04/09/2026. These failures could place residents at risk of injury due to unnecessary access to potentially harmful substances. Findings include: Record review of Resident #21's face sheet dated 04/09/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmission on [DATE]. Resident #1 had diagnoses which included angina pectoris (chest pain or discomfort caused 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-04-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
  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, and interviews the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety and nutrition services for facility residents.1. The facility failed to ensure food items were properly labeled and dated in the Resident Guest Refreshment Room, located on 400 hall.2. The facility failed to ensure foods were properly sealed in the Resident Guest Refreshment Room, located on 400 hall.3. The facility failed to ensure the Resident Guest Room, on 400 hall did not present with a foul odor. These failures could place residents at risk of foodborne illness and disease.Findings include:On 04/09/26, during observation rounds in the Resident Guest Refreshment Room (a room designated for outside vendors and family members to store food items in a refrigerator or freezer) located on the 400-hall, in the refrigerator, it was noted to have an unsecured, unlabeled and undated white bag inside. The bag was partially opened and inside the bag was a white styrofoam container with what appeared to be food items…

  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 · D2025-06-11 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a baseline for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for 1 of 5 residents ( Resident # 1) reviewed for care plans. The facility failed to develop a comprehensive care plan which addressed and included measurable objectives and timeframes related to Resident # 1's pressure wound of the left lateral thigh (a position or direction that is away from the midline or middle of the body) thigh which she had since her admission 4/24/2025. This deficient practice could affect any resident and contribute to residents not having their needs met according to their assessment. The findings were: Review of Resident # 1's face sheet, dated 6/5/2025, revealed she was admitted to the facility on [DATE] with diagnoses including: Conversion Disorders with Seizures or Convulsions (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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-02-22 · tag F0640 — pattern
  Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after a facility completes the resident's assessment for 2 out of 3 residents, (CR #96 and CR #97) reviewed for MDS transmission. -The facility failed to transmit a completed Discharge MDS assessment for CR #96 within 14 days of completion. -The facility failed to transmit a completed Discharge MDS assessment for CR #97 within 14 days of completion. These failures could place residents at-risk of not having their assessment completed and submitted timely, which could result in denial of services and or payment for services. Findings included: Record review of CR #96's admission Record revealed a [AGE] year-old male. CR #96 had an admission date of [DATE] and discharge date of [DATE]. CR #96 diagnoses included acute on chronic systolic (congestive) heart failure (refers to a sudden worsening of symptoms in a patient who already has a chronic condition of systolic 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-22 · tag F0761 — failed to label and store drugs safely — pattern
  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 and interview the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for and 3 (shared medication cart between Hall 100 and 400, 200 and 300 ) of 6 medication carts reviewed for medication storage. - The facility failed to ensure the 200,300, shared 100 and 400 hall medication carts did not contain eyedrops, ointment, and nasal spray that were opened but not labeled with the resident's name and not dated. This failure could place residents at risk of adverse medication reactions and infections. Findings Include: During observation on 02/19/25 at 2:50 PM, the following medications were found in the medication carts for 200 hall with LVN AA: Serevent Diskus (Salmeterol Xinafoate inhalation powder) open and not dated Trelegy Ellipta 200 mcg inhalation power open and not dated Nystatin & Triamcinolone Acetonide…

  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 · Ecited before2025-02-22 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Resident #31, Residents #41 and Resident #76) reviewed for infection control practices. - The facility failed to ensure CNA C followed proper infection control and hand hygiene for Resident #31 during Foley and incontinent care. - CNA AA did not utilize appropriate hand hygiene during Foley catheter care for Resident #41 - CNA AA did not utilize appropriate hand hygiene during incontinent for Resident #41 - The facility failed to ensure CNA F Donned proper PPE while providing incontinent care for Resident # 76 who was in enhanced barrier precaution isolation. These failures could place residents at risk of infection or a decline in health. The findings include: Resident #31 Record review of…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-22 · 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 for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 21 (Resident #44) residents for dignity. -RT A pushed Resident #44 into the dining room with his catheter bag strapped onto his leg which had urine in it and was exposed with no privacy cover. This failure could put residents at risk of psychosocial distress from failure to protect their dignity. Findings included: Record review of Resident #44's face sheet last captured 02/20/2025 revealed a [AGE] year-old male originally admitted on [DATE] and most recently admitted on [DATE]. His medical diagnoses included cognitive communication deficit, muscle wasting and atrophy (decrease in muscle function), Type 2 Diabetes Mellitus, and Alzheimer's Disease. Record review of Resident #44's Quarterly MDS dated [DATE] revealed a BIMS (assessment for resident's…

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

  Resident Rights 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

$127,277 in federal fines across 3 penalties.

• $17,345 — penalty dated 2026-02-09
• $16,149 — penalty dated 2025-02-22
• $93,783 — penalty dated 2023-08-24

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 HMG HEALTHCARE — 31 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 40 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.

9 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 2024. 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, FY2024). 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