Terra Bella Health and Wellness Suites

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.

Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 52% 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 128 beds and averages 106.8 residents a day — about 83% occupied, or roughly 21 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 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.547 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 2.97 hrs/resident/day on weekends vs 3.51 on weekdays — 15% thinner on weekends. RN hours go from 0.59 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 62% is well above the national median of 45%. 1 administrator has left in the past year.

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.

45 citations, most serious first. The 22 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · K2025-07-21 · 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 reviews, the facility failed to protect the resident's right to be free from abuse, neglect, and exploitation for 1 of 5 residents (CR #1) reviewed for neglect.-The facility failed to have structures and processes in place to ensure CR #1's wound was identified, and interventions were implemented. CR #1, who had PAD (a specific form of PVD in which there is narrowing of blood vessels taking blood to the extremities, leading to low or no oxygen), diabetes and a previous right-side AKA, did not receive podiatry services and nail care from admission on [DATE] until she discharged to the hospital on [DATE] (9 months). CR #1's had a wound to her left big toe documented in weekly skin assessments from 01/29/25 until 06/17/25, and there were no interventions implemented prior to hospitalization. At the hospital, CR #1 was diagnosed with gangrene and osteomyelitis (bacterial bone infection), with a recommendation for a left side AKA and ultimately placed on hospice services.…

  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 before2025-07-21 · 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, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 Residents (CR #1 ) reviewed for care plans. - The facility failed to develop and implement a plan of care for CR #1's PAD ( a specific form of PVD in which there is narrowing of blood vessels taking blood to the extremities, leading to low or no oxygen), which resulted in CR #1 not receiving podiatry care from admission on [DATE] till she discharged to the hospital on [DATE] (9 months) where she was diagnosed with a osteomyelitis (bacterial bone infection), with a recommendation for a left side AKA and ultimately placed on hospice services. An Immediate Jeopardy (IJ) was identified on 07/09/2025. The IJ template was provided to the…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-07-21 · tag F0687 — failed to care for feet properly — pattern
  Provide appropriate foot care.
  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 ensure residents received proper treatment and care to maintain mobility and good foot health, and provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and assist the resident in making appointments with a qualified person for 1 of 5 residents (CR #1) reviewed for foot care - The facility failed to provide foot care or attain podiatry services for CR #1, a diabetic patient with severe PAD (a form of PVD in which narrowing of the blood vessels limit blood flow to the limbs) and a history of AKA from admission on [DATE] till she discharged on 06/17/25 to the hospital where she was diagnosed with osteomyelitis (a bone infection) that needed antibiotics, an AKA was recommended resulting in the family placing the resident on end of life care. An Immediate Jeopardy (IJ) was identified on 07/09/2025. The IJ template was provided to the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-02-24 · 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 observations, interviews, and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent ulcers and not develop pressure ulcers for 1 of 8 residents, CR #1, reviewed for pressure ulcers. 1. LVN A failed to follow the facility's protocol and initiate adequate wound interventions when CNA B noted CR #1 had redness to her buttocks area on 01/04/2025 until 01/20/2025 when CR #1 was noted to have a stage 3 (a full-thickness tissue loss where the subcutaneous fat layer is visible within the wound, but the bone, tendon, or muscle is not exposed) sacral pressure ulcer, and an unstageable pressure injury (a type of pressure ulcer where the depth of the wound cannot be determined due to the presence of slough or eschar) (the wound was initially staged as a 3, but was changed to unstageable on 02/06/2025) to her right buttock. 2. The facility failed to ensure nurses completed comprehensive weekly skin assessments for CR #1 and resulted in 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
• Immediate jeopardy · Kcited before2024-01-18 · 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, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 14 residents (Resident#3 and #4) reviewed for pressure ulcers. -The facility failed to provide adequate treatment services to heal pressure ulcers for Resident #3's wound infection on the right buttock, stage 4 pressure ulcer injury that was noted on doctor's order for 12/29/2023. -The facility failed to ensure supplies were available for the ADON to provide adequate wound care treatment to Residents #3 and #4 on 1/14/2024. The ADON made her own dry dressing while providing treatment to Residents #3's and Resident #4's pressure ulcer by using gauze and tape. There were no sacral dressings or border gauze available for use. -The facility failed to follow the physician's orders while providing wound care treatment to 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2023-11-14 · 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 1 resident (Resident #1) of 5 residents reviewed for pharmacy services, in that: -Resident #1's Lacosamide (anticonvulsant) medication was not refilled when needed. -Resident #1's Lacosamide medication ran out. -Resident #1 missed 9 doses of Lacosamide (anticonvulsant medication) that lead to Resident #1 having a tonic-clonic seizure (uncontrolled tightening and loosening of muscles that cause convulsions) and resulted in hospitalization. An Immediate Jeopardy (IJ) was identified on 11/13/2023. While the IJ was removed on 11/14/2023, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the need to evaluate the effectiveness of the corrective systems. Findings include: Record review of the Face Sheet…

  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
• Immediate jeopardy · Kcited before2023-11-14 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  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 1 resident (Resident #1) of 5 residents reviewed for medications was free of any significant medication errors, in that: -Resident #1's Lacosamide (anticonvulsant) medication was not refilled when needed. -Resident #1's Lacosamide medication ran out. -Resident #1 missed 9 doses of Lacosamide (anticonvulsant medication) that lead to Resident #1 having a tonic-clonic seizure (uncontrolled tightening and loosening of muscles that cause convulsions) and resulted in hospitalization. An Immediate Jeopardy (IJ) was identified on 11/13/2023. While the IJ was removed on 11/14/2023, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the need to evaluate the effectiveness of the corrective systems. Findings include: Record review of the Face Sheet (undated) for Resident #1 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2023-10-28 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  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 1 resident (Resident #8) of 8 residents was free of any significant medication errors, in that: -Resident #8's thyroid medication was discontinued without a physician order. -Resident #8 missed 30 daily doses of the thyroid medication. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 08/23/23 and ended on 09/28/23. The facility corrected the noncompliance before the survey began. The failure led to Resident #8 having a TSH lab value that was Critical High. Findings include: Record review of the Resident Face Sheet for Resident #8 (no date) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, cognitive communication deficit (decreased ability to speak and understand), hypothyroidism (disorder of the endocrine system in which the thyroid does not produce enough thyroid hormone), and dementia (a group of thinking 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · H2026-05-23 · tag F0697 — failed to manage pain — pattern
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 9 residents (Resident #1) reviewed for pain management. The facility failed to timely identify Resident #1's pain following a fall as a change in condition, failed to appropriately assess the pain, and failed to ensure ongoing monitoring and communication of the resident's pain status. Resident #1 was observed yelling in pain during care and received pain medication for more than 24 hours before the pain was fully assessed and later required hospital evaluation, a pain management regimen, and experienced a decline in functional abilities. This failure placed residents at risk for delayed assessment and treatment, unmanaged pain, functional decline, and hospitalization Findings included: Record review of Resident #1'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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-05-23 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 9 residents (Resident #1) reviewed for notification of changes. The facility failed to timely consult Resident #1's physician after she reported right leg/knee pain following a fall. Resident #1 complained of pain the evening of the fall and again the following morning; however, the physician was not consulted until more than 24 hours after the initial complaint. Resident #1 later required hospital evaluation, changes to her pain management regimen, and experienced a decline in functional abilities. This failure placed residents at risk for delayed assessment and treatment, unmanaged pain, functional decline, and hospitalization.Findings included: 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-05-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the resident environment remained free of accident hazards as was possible for 1 of 9 (Resident #1) reviewed for accidents, in that Resident #1 was lowered to the floor when staff attempted to transfer Resident #1 while she remained wet from her shower and utilized an inappropriate transfer technique. Following the incident, Resident #1 complained of knee pain, required hospital evaluation, was placed on a pain management regimen, and experienced a decline in functional abilities. This failure placed residents at risk for falls, injury, increased pain, hospitalization, and further decline in functional abilities.Findings included: Record review of Resident #1's facesheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Cerebral infarction (type of stroke that occurs when blood flow to a part of the brain is blocked or significantly reduced, depriving brain tissue of oxygen and vital…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Hcited before2025-02-24 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming for 1 of 8 residents (CR #1) reviewed for ADL's. 1. The facility failed to ensure CR #1's hair was adequately washed and combed for an unknown period and resulted in a thick accumulation of a brown, flakey substance on her entire scalp, and a large amount of matted hair in the back of her head which had to be cut off. 2. The facility failed to ensure CR #1's nails were cut and appropriately groomed which resulted in an accumulation of a dark brown/black substance underneath the nails. 3. The facility failed to notify CR #1's RP and physician that she had matted hair and an accumulation of a brown, flakey substance on her scalp which resulted in a delay in treatment/care. These failures placed dependent residents at risk of experiencing scalp itch, odors, infection, skin tears, and undesirable haircuts.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-09 · 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 observation, record review and interviews, the facility failed to ensure the resident's environment remains as free of accident hazards as is possible and residents received adequate supervision to prevent accidents for 1 out of 5 residents (Resident # 1) reviewed for quality of care.The facility failed to ensure Resident # 1's head of bed was upright and elevated, and that Resident # 1 was closely supervised during and after administration of oral medications on 5/23/26.This failure places residents at risk of aspiration and choking when administering oral medications. Findings include: Record review of Resident # 1's Face Sheet revealed a [AGE] year-old female with an admission date of 3/29/2023. Diagnoses were hypertension (a chronic medical condition in which the force of blood against your artery walls is consistently too high), unspecified dementia (used when a patient exhibits a clear decline in cognitive abilities (such as memory loss or problem-solving), but the underlying cause or specific…

  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 no plan of correction
• Potential for harm · D2026-05-23 · 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 record review and interview, the facility failed to ensure residents had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 9 residents (CR #3) reviewed for resident rights. The facility failed to provide CR #3 a hot meal upon admission to the facility. CR #3 requested to receive the hot dinner meal being served to other residents; however, the facility did not provide the requested meal and later offered a sandwich and snacks, which she declined. As a result, CR #3's family had to provide her with a hot meal. This failure placed the resident at risk for loss of dignity, unmet nutritional needs, emotional distress, and diminished quality of life.Findings included: Record review of CR #3's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged on 5/8/2026 to the hospital. Her diagnoses included: Metabolic encephalopathy (brain dysfunction caused by chemical 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-26 · tag F0759 — failed to keep medication error rate low — pattern
  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 its medication error rate was not five percent or greater for 2 residents (Resident #10 and Resident #3) of 6 residents observed for Medication Pass. -Resident #10 was administered 9 medications that were prescribed to Resident #107. -Surveyor intervention prevented Resident #3 from receiving one medication that was prescribed to Resident #103. -The medication pass observation yielded 10 errors of 27 opportunities and resulted in a 37% error rate. The failure placed residents at risk of having harmful effects from being administered the wrong medications. Findings included:Record review of the Face Sheet for Resident #10 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included cerebral infarction (stroke), left side hemiplegia (loss of use of the left side), diabetes type 2, hypertension (high blood pressure), and embolism and thrombosis (blood clot) of an unspecified artery.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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-01-13 · 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 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 one resident (Resident #1) of four residents reviewed for infection control. -Staff providing incontinent care for Resident #1 threw wet and/or soiled incontinent pads onto the floor. The failure placed the resident, visitors and staff at risk for acquiring infection. Findings include:Record review of the Face Sheet (no date) for Resident #1 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia (decline in cognitive ability), muscle wasting, and dysphagia (difficulty swallowing). Record review of Resident #1's Quarterly MDS, dated [DATE] revealed the resident had severely impaired cognition. The resident had limited functional range of motion…

  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 · D2026-01-13 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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 nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one resident (Resident #1) of four residents reviewed for dietary services. -CNA C was in her first day of orientation and was assigned to assist Resident #1 with eating with no supervision. -Resident #1 had a diagnosis of dysphagia (difficulty swallowing). The failure placed Resident #1 at risk for choking and/or aspiration.Findings Include:Record review of the Face Sheet (no date) for Resident #1 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia (decline in cognitive ability), muscle wasting, and dysphagia (difficulty swallowing).Record review of Resident #1's Quarterly MDS, dated [DATE] revealed the resident had severely impaired cognition. The 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-26 · 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 observation, interview, and record review, the facility failed to ensure, based on the comprehensive assessment of the resident that one resident (Resident #1) of four residents reviewed for quality of care received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan.Resident #1 had a wound dressing that was wet during a shower procedure and was not changed prior to being sent to an appointment.The failure could place the resident at risk for not receiving necessary care and treatment.Findings included:Record review of the Face Sheet for Resident #1 revealed she was [AGE] years old and was admitted on [DATE]. Diagnoses included, but were not limited to, unspecified wound of her left foot, subsequent-encounter left heel infection, and cognitive communication deficit.In an interview via telephone on 10/14/2025 at 11:20 a.m., a family member said Resident #1 had a wound care doctor's appointment the previous day. She said when the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #2) of four residents reviewed received adequate supervision and assistance devices to prevent accidents, in that:Resident #2 was lifted in a mechanical lift by a single staff, although the lift requires two people.Resident #2 was suspended in the air in the and moved by a single staff. The resident was swinging, with her weight shifting side to side.The failure could place residents at increased risk for inadequate supervision.Findings include:Record review of the Face Sheet for Resident #2 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia, contractures of both shoulders, and muscle wasting and atrophy.Record review of Resident #2's Quarterly MDS, dated [DATE] revealed the resident had severely impaired cognition. The resident had limited functional range of motion in both arms and both legs. The resident required maximum assist…

  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 before2025-11-20 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record reviews, the facility failed to provide pharmaceutical services, including procedures that assured the accurate administration of all drugs and biologicals to meet the needs of 1 of 1 (Resident # 1) reviewed for enteral medication administration.LVN A failed to administer Resident # 1's enteral medications according to physician's order. This failure could place residents at risk for a clogged peg tube, adverse reaction, metabolic abnormalities and a decline in health. Findings included: Record review of Resident # 1's face sheet retrieved on 11/18/2025 at 09:53 a.m., revealed, Resident # 1 was an [AGE] year-old female admitted to the facility on [DATE]. She was admitted with the following medical diagnoses: Unspecified dementia(loss of cognitive functioning), gastrostomy status, ( the condition or situation of a patient who has undergone a medical procedure that involves placing a tube directly into the stomach for feeding or medication administration) hypertension…

  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 before2025-07-21 · tag F0641 — isolated
  Ensure each resident receives an accurate 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 observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 5 residents (CR #1) reviewed for accuracy of assessments. - The facility failed to identify CR # 1's diagnosis of vascular diseases (narrowing of the blood vessels that result in oxygen not getting sent to the limbs also called PVD) and document it in her MDS(s) which resulted in CR #1 not having a plan of care for her diagnosis. These failures could place residents at risk of a compromised plan of care, worsening of health conditions, infection, injury, and amputation. Findings include: Record review of CR #1's Face Sheet dated 06/22/25 revealed, a 69-year-olf female who admitted to the facility on [DATE] at 12:45 PM with diagnosis which included: Alzheimer's Disease, unspecified dementia with anxiety, hypertension (high blood pressure), acquired absence of right leg above knee (right above the knee amputation) and type 2 diabetes with other circulatory complications.…

  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 · D2025-07-21 · 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 1 of 1 medication carts (100 Hall Nurse Cart) reviewed for medication storage . - LVN D failed to ensure the 100-200 Hall Nursing cart was locked when not under direct supervision of authorized staff. This failure could place residents at risk of adverse reactions to medications and misappropriation of medications.Findings included: An observation on 07/10/25 starting at 08:55 AM revealed, an unlocked and unattended nursing cart in front of room [ROOM NUMBER] and #115. The back of the cart was pushed against, and the drawers were exposed to the hallway. At 09:00 AM LVN D walked from behind the double doors that led to the hall with the dining area and kitchen and walked up to the unattended cart.In an observation and interview…

  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

“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

$181,644 in federal fines across 6 penalties.

• $24,740 — penalty dated 2026-05-23
• $45,679 — penalty dated 2025-07-21
• $26,943 — penalty dated 2025-02-07
• $38,705 — penalty dated 2024-01-18
• $32,548 — penalty dated 2023-11-14
• $13,029 — penalty dated 2023-10-10

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 FUNDAMENTAL HEALTHCARE — 66 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 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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.

About 85% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $318K paid to related parties (affiliated landlords or management companies) in its most recent 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