Woodway Nursing & Rehab

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.

37.7% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 25.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 20 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.83 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 112 beds and averages 45.2 residents a day — about 40% occupied, or roughly 67 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.68 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.28 hrs/resident/day on weekends vs 3.84 on weekdays — 15% thinner on weekends. RN hours go from 0.54 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 85% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

Deficiencies are 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.

55 citations, most serious first. The 30 most serious are shown; the remaining 25 are one tap away and print in full.

• Immediate jeopardy · Kcited before2026-03-05 · 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 that residents with pressure ulcers receive necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 5 residents reviewed for wound prevention. The facility failed to provide Resident #1 wound care every day shift as ordered on 2/23/26, 2/24/26, and 2/25/26 for his 6 documented wounds. Pressure wound on Resident #1's left hip developed a strong odor with moderate serosanguinous fluid. Wound Care Doctor (WCD) diagnosed the wound as infected on 2/27/26. An IJ was identified on 03/01/256. The IJ template was provided to the facility on [DATE] at 3:30 p.m. While the IJ was removed on 03/02/26, the facility remained out of compliance at a scope of pattern and a severity level of not actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to monitor 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 · Jcited before2026-03-05 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders for 1 (CR#1) of 45esidents reviewed for advanced directives. CR #1 was found unresponsive on [DATE]. LVN A failed to perform CPR on resident or contact Hospice A for further instruction. CR#1 was pronounced deceased on [DATE] at 6:20 p.m. The noncompliance was identified as Past Non-Compliance. The IJ began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. The failure could place residents at risk of experiencing a diminished quality of life and death. The findings included:Record review of CR#1's facesheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His admitting diagnoses were dementia, cerebral infraction (stroke), and COPD (Chronic Obstructive Pulmonary Disease). Advance directives stated that he…

  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 · L2025-06-19 · tag F0835 — failed to run the facility competently — widespread
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  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 it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the entire facility which included: 2 residents who experienced abuse (Resident #113 & Resident #114), 3 residents who experienced problems with services for treatment and services for mental and psychosocial concerns (Resident #30, Resident #42 & Resident #52); 2 resident who experienced repeated G-tube dislodgement (Resident #18 & Resident #33); 2 residents who experience problems with ADL care (Resident #28 & Resident #109), 3 residents who experienced significant medication errors and problems with quality of care (Resident #161, Resident #162, Resident #163); pharmacy services & physical environment reviewed for administration. - Facility administration failed to have an effective system that identified and put interventions in place to…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-06-19 · 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 two residents (Resident #111, #113 and #114) out of seven reviewed for abuse. The facility failed to protect Resident #113 and #114 from a physical altercation on 3/23/25. Resident #114 sustained redness and pain to the left eye and sent to the ER. The facility failed to address Resident # 114's continued threatening and aggressive behavior towards residents and staff. The facility failed to address Resident #113's inappropriate sexual behavior on 5/03/2024 towards an unknown female resident as documented in the medical records. An Immediate Jeopardy (IJ) was identified on 05/03/2025. The IJ template was provided to the facility on [DATE] at 1:58 PM. While the immediacy was removed on 05/08/2025 at 1:24 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, 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 · Kcited before2025-06-19 · 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 7 of 10 Residents (Resident #18, Resident #28, Resident #30, Resident #33 , Resident #52, Resident #113 & Resident #114 ) reviewed for care plans. - The facility failed to develop and implement a care plan that addressed Resident #18's behaviors of pulling on and pulling out her G-tube which resulted in the resident pulling out her G-tube in 11/12/24, 03/28/25 and 04/15/25 which required hospitalization to place a new tube. - The facility failed to develop and implement a care plan that addressed Resident #33's behaviors of pulling out his G-tube which resulted in the resident pulling out his G-tube on 02/04/25, 02/12/25, 02/23/25 and 04/15/25 which…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-06-19 · tag F0678 — failed to provide CPR when needed — pattern
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  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 ensure personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 5 ( Resident #161) residents and 2 out of 2 Crash Carts in that: - RN D failed to use the AED when providing CPR to Resident #161 when he was found unresponsive on [DATE]. - The facility failed to ensure the facility had pads for use with the AED in case a resident was in need of CPR. - The facility failed to ensure the facility crash carts had oxygen available. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 02:12 PM. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to evaluate…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-06-19 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 3 of 9 residents (Resident #161, Resident #162 and Resident #163) reviewed for quality of care. - LVN T failed to enter orders for potassium to treat Resident #161's critically low potassium of 2.7 correctly which resulted in Resident #161 receiving his first dose of potassium over 12 hours after the lab notified LVN T of the critical lab result and Resident #162 receiving 2 doses of Potassium in error. - RN E failed to notify Resident #163's physician of his critically high BUN of 93 correctly by sending a picture to the incorrect provider after hours instead of notifying the on-call physician and failed to conduct a CIC evaluation for the resident. These failures could place residents at risk of delay in care, worsening of health conditions, adverse reactions, hospitalization, and death. An IJ was identified on [DATE]. The IJ…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-06-19 · tag F0693 — failed to provide proper feeding-tube care — pattern
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 2 (Resident #18 and Resident #33 ) of 7 residents reviewed for enteral nutrition. - The facility failed to provide treatment and services, which included an abdominal binder, to prevent complications of enteral feeding due to Resident #18's behaviors of pulling on and pulling out her G-tube which resulted in: the resident pulling out her G-tube on 2 occasions (11/12/24 and 04/15/25) which required hospitalization to place a new tube; and on 1 occasion (03/27/25) the resident pulling on her G-tube and an IV pole falling on her head on. - The facility failed to provide treatment and services, which included an abdominal binder, to prevent complications of enteral feeding due to Resident #33's behaviors of pulling out his G-tube which resulted in the resident pulling out his G-tube on 3 occasions…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-06-19 · tag F0742 — pattern
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 3 of 8 residents (Resident # 30, Resident #42 Resident #52) reviewed for treatment and services for mental and psychosocial concerns. - The facility failed to provide appropriate treatment and services to prevent and correct Resident #30's escalating behaviors which resulted in a suicide attempt on 04/13/25 and the resident attempting to draw a police officer's firearm when she had to be forcefully restrained and removed from the facility. - The facility failed to provide appropriate treatment and services to prevent and correct Resident #52's escalating behaviors which resulted in suicide threats and an incident on 05/03/25 when the resident had to be forcefully restrained 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-06-19 · 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 observations, interviews, and record reviews the facility failed to ensure residents were free of significant medication error for 3 of 7 residents (Resident #31, Resident #161, and Resident #162) reviewed for significant medication errors. - The facility failed to administer Potassium 40 mEq immediately to Resident #161 after he had a critical potassium lab value of 2.7. - The facility failed to ensure Resident #162 was not administered Potassium 40 mEq in error. -The facility failed to administer Resident #31's seizure medications (Lacosamide and Clonazepam) and IV antibiotic (Meropenem) after he readmitted to the facility from a short-term hospital stay even though the medication was in the facility. This failure could place residents at risk of side effects of medications, worsening of health conditions, increased chance of seizures, cardiovascular arrest, brain damage and death. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 04:36 PM. While the IJ was…

  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 · Lcited before2025-03-12 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely for 18 of 18 residents reviewed (CR #1, Resident #2, #3, #4, #5, #6, #7, #10, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) and 4 of 4 Halls (A, B, C & D Halls) reviewed for clean, comfortable, homelike environment, and clean bed and bath linens. - The facility failed to maintain a clean and homelike environment for all residents across the facility. - The facility failed to provide adequate clean linens (towels & Sheets) to meet the needs of all residents across all units which resulted in residents (CR#1, Resident #2, #7, #5, #3) who reported they stuck to their mattress, felt cold, unclean, dirty, worthless, neglected, and left CR #1 in tears. - The facility failed to provide adequate clean linens as Residents #6, #10, #21, #22, #24, #25, #26, #27, #28, #29 & #30 were…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2025-03-12 · tag F0600 — failed to protect residents from abuse and neglect — widespread
  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, interview and record review, the facility failed to ensure all residents were free from neglect for 18 of 18 residents (CR #1, Resident #2, #3, #4, #5, #6, #7, #10, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) and 4 of 4 Halls (A, B, C & D Halls) reviewed for neglect. - The facility failed to provide adequate clean linens (towels & Sheets) to meet the needs of all residents across all units which resulted in residents (CR#1, Resident #2, #7, #5, #3) who reported they stuck to their mattress, felt cold, unclean, dirty, worthless, neglected, and left CR #1 in tears. - The facility failed to provide adequate clean linens as Residents #6, #10, #21, #22, #24, #25, #26, #27, #28, #29 & #30 were observed laying on bare mattresses. - The facility failed to provide hot water in resident rooms & showers which resulted in residents receiving cold showers or no showers at all. - The facility failed to ensure there was hot water in rooms C6- C8, C-13, D-1, D-10, C Hall shower, C-Hall sink, and D…

  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 before2025-03-12 · 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 to ensure services provided, met professional standard of quality for 1of 1 resident (Resident #6) reviewed for professional standards. - The facility failed to follow Resident #6's care plan by not applying a hand roll to his contracted left hand. This failure could place residents at risk of worsening of contractures, pain and deterioration of health. Findings included: Record review of Resident #6's face sheet dated 03/10/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] His initial admission was 11/21/2022 and his original admission was 02/26/2018. His diagnoses included acute respiratory failure with hypoxia (inadequate gas exchange by the respiratory system), dependence on supplemental oxygen, Hemiplegia (one sided paralysis), Hemiparesis (paralysis to one side of body), stroke, chronic obstructive pulmonary disease (a lung condition caused by damage to the airway), anemia (reduced number of red blood cells),…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-03-12 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practices, the comprehensive care plan, and the residents' choices and based on the comprehensive assessment of a resident for 1 of 1 resident (Resident #6) reviewed for quality of care. - The facility failed to provide follow up care to Resident #6's left hand middle finger after an injury involving staff resulted in bleeding and pain. This failure could place residents at risk of pain and infection. Findings included: Record review of Resident #6's face sheet dated 03/10/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] His initial admission was 11/21/2022 and his original admission was 02/26/2018. His diagnoses included acute respiratory failure with hypoxia (inadequate gas exchange by the respiratory system), dependence on supplemental oxygen, Hemiplegia (one sided paralysis), Hemiparesis (paralysis to one side of body),…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-11-13 · 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 of three residents (Resident #1) received adequate supervision and that the resident environment remained as free of accident hazards as is possible, in that: The facility failed to ensure Resident #1 was served coffee at a safe temperature which resulted in a burn to her left hand. The facility failed to ensure a temperature log was kept to document temperatures of coffee prior to distribution and service to residents. An immediate jeopardy of past non-compliance was identified on 11/13/2024 at 1:30PM. The IJ template was provided to the facility Administrator on 11/13/2024 at 2:50PM. The Immediate Jeopardy was determined to have existed from 10/20/24 to 10/22/2024 due to the facility's implemented actions that corrected the non-compliance prior to survey entry. This failure injured Resident #1 and placed other resident at risk of injury, burns, pain, anxiety, and a decreased quality of life. Findings included: Record review…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · K2023-12-08 · tag F0580 — failed to tell family and doctor about changes — pattern
  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 immediately consult with the resident's physician when there was a significant change in the resident's physical status for 1 (Resident #1) of 3 residents reviewed for notification of changes. -The facility failed to notify the primary doctor (MD B) of Resident #1's pressure ulcers that were observed 10/6/23 to11/16/23 resulting in Stage. An Immediate Jeopardy (IJ) was identified on 12/7/2023. The IJ template was provided to the facility on [DATE] at 4:03 pm. While the IJ was removed on 12/8/2023 at 3:45 pm, the facility remained out of compliance at a severity of actual harm that is not IJ with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for delayed treatment, deteriorating pressure ulcers, infections, and hospitalization. Findings include: Record review of Resident #1's undated face sheet, revealed he was a [AGE] year-old male, who…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2023-12-08 · 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 interview, observation, and record review the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers, promote healing, and to prevent new ulcers from developing for 3 (Resident #1, Resident #2, and Resident #3) of 7 residents reviewed for pressure ulcers. -The facility failed to turn/re-position Resident #1 and Resident #2 every 2 hours who were completely dependent and bed bound to prevent Pressure Ulcer development. -The facility failed to perform accurate skin assessments for Resident #1 (10/13/23 to 10/27/23) and Resident #2 (11/7/23 to 12/4/23) for Pressure Ulcers. -The facility failed to treat Resident #1's facility acquired pressure ulcers for over a month after being identified by Wound Care Nurse on 10/6/23 (sacrum, knee, buttocks, bilateral heels) . -The facility failed to identify Residents #2's risk for Presure Ulcers related to incontinence of bowl/bladder and bedbound, treat, and prevent further damage of Resident…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-06-05 · 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 observation, interview, and record review, the facility failed to develop a base-line person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 9 residents (CR #1) reviewed for base-line care plans. The facility failed to provide CR #1 with a base-line personal-centered care that addressed, monitored, and managed the development of wounds to CR #1's posterior area. This failure places residents at risk for appropriate care, treatment, monitoring, and timely assessment for the development of infections, resulting in hospitalization, a decline in health, or death. Findings included: Record review of CR #1's face sheet dated 06/03/2026, revealed that he was a [AGE] year-old male who originally admitted on [DATE] and discharged on 06/02/2026 with diagnoses including injury of head, displaced comminuted fracture (several breaks where the bone shatters into three or more pieces and the fragments are pushed out of…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has no plan of correction
• Actual harm · Gcited before2026-06-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 4 residents (CR #1) reviewed for ADLs. The facility failed to ensure CR #1, a resident with wounds, was provided with personal grooming, showers, and bed baths on the 2:00 p.m. to 10:00 p.m. shift. These failures could place residents at risk for skin breakdown, offensive odors, or infections, resulting in a decline in health, hospitalization, or dealth. Findings included: Record review of CR #1's face sheet dated 06/03/2026, revealed a [AGE] year-old male who originally admitted on [DATE] and discharged on 06/02/2026 with diagnoses including traumatic subarachnoid hemorrhage (bleeding into the fluid-filled space between the brain and the protective tissue covering) with loss of consciousness, injury of head, displaced comminuted fracture (several breaks where…

  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
• Actual harm · Gcited before2026-06-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that a resident with pressure ulcers receives necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 9 residents (CR #1) reviewed.The facility failed to ensure CR #1, received orders, monitoring, and interventions to an existing wound and development of new wounds resulting in the lack of wound care management and hospitalization. These failures could place residents at risk of developing, reopening and worsening of pressure ulcers Findings included: Record review of CR #1's face sheet dated 06/03/2026, revealed that he was a [AGE] year-old male originally admitted on [DATE] and discharged on 06/02/2026 with diagnoses included traumatic subarachnoid hemorrhage (bleeding into the fluid-filled space between the brain and the protective tissue covering) with loss of consciousness, injury of head, displaced comminuted…

  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 · Ecited before2026-06-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record reviews and interviews, the facility failed to ensure resident environment remained as free of accident hazards as was possible for 1 of 4 shower rooms (A Hall shower room) reviewed for accidents. The facility failed to ensure the A Hall shower room was locked and sharps in the shower room were secured and not accessible to residents on 06/02/2026 and on 06/03/2026. This failure could place residents at risk of entering the shower room that and could harm themselves due to the presence of unsecured sharp items. During observations on 06/02/2026 at 10:02 a.m., and on 06/03/2026 at 3:10 p.m., the A Hall shower room door was ajar and accessible to residents. No residents or staff were in the hallway or inside the shower room at that time. Further observation on both days revealed staff stored 14 unopened disposable razors on an unsecured shelf inside the shower room. The razors were scattered and not inside a box or a container. The shower room did not contain a locked box or cabinet. In an interview on 06.03.3026 at 9:47 a.m., the Maintenance Director…

  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 · Dcited before2026-06-05 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals), to meet the needs of each resident 1 of 1 medical supply reviewed for medication storage and labeling. The facility failed to ensure the medication cart was free from expired medical supplies on 06/05/2026. This failure could place residents at risk of using items that were less effective or risky due to a change in their chemical composition and could cause infections due to compromised sterile equipment.Findings included: During an observation of C hall's medication cart and interview on 06/05/2026 at 9:36 a.m., revealed staff stored unopened expired Selan zinc oxide barrier cream (a medical and skincare topical ointment designed to form a protective layer on the skin, shielding it from moisture, irritants, and friction) count 17, all expired on 12/2025. In an interview on 06/05/2026 at 9:40 a.m., LVN Q stated she checked the medication cart for…

  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 no plan of correction
• Potential for harm · Dcited before2026-01-16 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  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 keep confidential all information contained in the resident's records, regardless of the form or storage method of the records or safeguard medical record information against loss, destruction, or unauthorized use for 1 (Hall C) of 2 halls observed for privacy and failed to keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is to the individual, or their resident representative where permitted by applicable law or required by law for 1 (CR#1) of 1 residents reviewed for medical records. -CNA B left a computer logged into the medical record system unattended on 1/16/2025 at 10:52am.-The facility failed to respond to CR #1's representative's attempts for medical records requests on 5/21/2025, 6/24/2025, 7/9/2025, 7/22/2025 and 09/12/2025. This failure could place residents at risk of their personal health information being exposed to…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-11-06 · 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 that its residents are free of any significant medication errors for 1 (Resident #1) of 4 residents reviewed for medication administration. RN B failed to call the hospital, ADON, and Administrator on 11/04/25 when she did not receive report from the hospital when Resident #1 returned to the facility from the hospital on [DATE]. The facility failed to administer Resident #1's IV Vancomycin 1gm evening dose on 11/04/25 and morning dose on 11/5/25. The facility failed to administer Resident #1's IV Meropenem 500mg every 4 hours when he returned to the NF on 11/04/25 from the hospital. The facility did not initiate the medication until 11/05/25 at 8:00PM. Resident #1 missed a total of 4 doses. This failure could place residents at risk of prescribed antibiotics not working effectively to treat residents' infections. Findings: Record review of Resident #1's face sheet dated 11/05/25 revealed a [AGE] year-old-male admitted to the NF…

  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 before2025-11-06 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety for 1 (Resident #1) of 4 residents observed for cleanliness of rooms. Housekeeping failed to clean Resident #1's room prior to being admitted from the hospital to facility on 11/04/25. This failure placed residents at risk for cross contamination. Findings: Record review of Resident #1's face sheet dated 11/05/25 revealed a [AGE] year-old-male admitted to the NF initially on 05/07/25 and again on 11/04/25. Resident #1's diagnoses included the following: respiratory failure with hypoxia (low oxygen levels in the body), cerebral infarction (blood flow to a part of the brain is blocked), sepsis (bacterial infection in the body that could lead to organ failure and death), type 2 diabetes mellitus (when blood sugar in the body is too high), pneumonia (infection of the lungs), muscle wasting 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-06 · tag F0880 — failed to prevent and control infections — isolated
  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 maintain an infection control program to provide a safe, sanitary, and comfortable environment to help prevent the transmission of infection for 1 of 4 residents (Resident # 2,) reviewed for infection control in that: CNA D failed to don (to put on) disposable gown when providing direct care for Resident #2 who was on Enhanced Barrier Precautions on 11/05/25. This failure could place residents at risk for cross-contamination and unwanted infections. Findings include: Record review of Resident #2's face sheet dated 11/06/25 revealed a [AGE] year-old-female admitted to the NF originally on 06/29/24 and again on 07/02/25. Resident #2's diagnoses consisted of the following: heart disease, type 2 diabetes mellitus (high blood sugar levels), pneumonia (infection in the lungs), dysphagia (difficulty swallowing), gastrostomy (surgical procedure to insert a feeding tube in to the stomach to allow liquid nutrition and medicine), end stage renal…

  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 · Fcited before2025-06-19 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record reviews, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 1 out of 1 laundry rooms reviewed for . - The facility failed to ensure the resident's laundry was washed and returned. There were 4 big barrels of dirty clothes in the laundry room that were not able to get washed and returned to the residents. This deficient practice could place residents at risk of missing clothes, and not having clean clothes to wear which could lead to a decreased quality of life. Findings included: In an interview on 04/15/25 at 09:47 AM Resident #28 said he was having problems getting clean laundry, the facility did not return his clothes. In an interview and observation on 4/17/25 at 10:30am with the Laundry Tech, there were 4 big barrels of dirty clothes in the laundry room, that belonged to the residents. The barrels of dirty clothes were piled so high the clothes were spilling over on to the floor. 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 · Fcited before2025-06-19 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 6 of 7 months (October 2024, November 2024, December 2024, January 2025, February 2025, March 2025) reviewed for nursing services. The facility failed to ensure a registered nurse worked on 2 out of 31 days in October of 2024. The facility failed to ensure a registered nurse worked on 4 out of 30 days in November of 2024. The facility failed to ensure a registered nurse worked on 9 out of 31 days in December of 2024. The facility failed to ensure a registered nurse worked on 4 out of 31 days in January of 2025. The facility failed to ensure a registered nurse worked on 2 out of 28 days in February of 2025. The facility failed to ensure a registered nurse worked on 3 out of 31 days in March of 2025. These failures could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings included: Record…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-06-19 · tag F0908 — failed to keep essential equipment working — widespread
  Keep all essential equipment working safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition for 1 of 2 (the left dryer) dryers reviewed for safe operating conditions. - The facility failed to clean the lint filter in a timely manner resulting in a thick layer of lint on the filter, around it, and below it. This failure could place residents at risk of injury, hospitalization, or death due to a fire. In an observation and interview on 4/17/25 at 10:30am with the Laundry Tech, he pulled out the lint filter for the dryer. There was a thick layer of lint on the filter, around the filter, and below the filter. He said he checked the filter when he got to work at 6am, again at 10:00am, and then before he left at 5:00pm. He said if there was a buildup of lint it could cause a fire. He also said he thought it should be checked more often. In an interview with the new Housekeeping Supervisor on 4/17/25 at 10:45am, she said she was going to be the new Supervisor over the Laundry Tech. She said there was too much lint 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-19 · tag F0552 — pattern
  Ensure that residents are fully informed and understand their health status, care and treatments.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure a resident's responsible party was informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose alternative options if he or she preferred for 7 of 8 residents ( Resident #11, Resident #42, Resident #45, Resident #52, Resident #54, Resident #159 and Resident #160) reviewed for resident rights. - The facility failed to get consent from Resident #45's RP prior to administering Quetiapine, a psychotropic ( medications that affect mental processes including mood, behavior, perception and thought) - The facility failed to have consent forms prior to administering antipsychotic medications to Residents #11 , #42, #45, #52, #54, #159 and #160 This failure could affect residents and/or responsible parties by placing them at risk of not being informed of treatment options . Findings included: Resident #45 Record review of Resident #45's Face Sheet dated 04/22/25…

  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

$305,625 in federal fines across 4 penalties. 1 Medicare payment denial on record.

• $28,120 — penalty dated 2026-03-05
• $207,010 — penalty dated 2025-03-12
• $15,891 — penalty dated 2024-11-13
• $54,604 — penalty dated 2023-12-08
• Medicare payment denial — starting 2025-06-12 for 64 days

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.

Who owns this facility

CMS files one row per role, so the 13 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

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