Fall Creek Rehabilitation and Healthcare Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

55.1% 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 174 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 50.9% 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 55 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 0.52 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 68% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 126 beds and averages 84.2 residents a day — about 67% occupied, or roughly 42 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 3.25 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.11 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.88 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 2.81 hrs/resident/day on weekends vs 3.43 on weekdays — 18% thinner on weekends. RN hours go from 0.10 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 66% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

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

22 citations, most serious first. The 17 most serious are shown; the remaining 5 are one tap away and print in full.

• Immediate jeopardy · K2025-04-13 · 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 observations, interviews, and record review, the facility failed to immediately inform and consult with the resident's physician when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) ensure the severity of changes in condition were reported to physician for resident (Resident #1) who required colostomy, urostomy, or ileostomy for 1 of 4 residents reviewed for change in condition in that: 1. The facility failed to when notify the NP of the severity of the change in condition and the difficulties the nursing staff were having keeping Resident #1's ileostomy system secure and in place. 2. The facility failed to obtain a new physician order due to resident's change in condition causing skin breakdown. Resident #1 discharged to the hospital and was diagnosed with a sepsis bacterial infection and an AKI. An IJ was identified on [DATE]. The IJ template was provided to the facility…

  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 · K2025-04-13 · tag F0691 — failed to provide colostomy / ostomy care — pattern
  Provide appropriate colostomy, urostomy, or ileostomy care/services 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 observations, interviews, and record review, the facility failed to ensure that residents who required colostomy, urostomy, or ileostomy services received such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 4 residents (Resident #1) reviewed for ostomy care in that: 1. The facility failed to ensure Resident #1's ileostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, to divert waste from the small intestine), wafer (the piece of the pouching system that sticks to your body and holds your pouch in place and should help protect the skin around your stoma from damage) and bag were in place. 2. The facility failed to empty Resident's #1's ileostomy bag timely and remain free from leakage. Resident #1 discharged to the hospital and was diagnosed with a sepsis bacterial infection and an AKI. An IJ was identified on [DATE]. The IJ template was provided to the facility on…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-02-05 · tag F0656 — failed to write and follow a full care plan — isolated
  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 observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs, for 1 (CR #1) of 5 Residents reviewed for care plans in that: The facility failed to develop a comprehensive person-centered care plan for CR #1 to address the risk for falls. This failure placed residents who were fall risk at risk of serious harm and injury. An Immediate Jeopardy (IJ) was identified on 1/16/2025. The IJ template was provided to the Administrator and DON on 1/16/2025 at 3:45pm. While the IJ was removed on 1/18/2025 at 1:11 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at an…

  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 · J2025-02-05 · 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 each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (CR#1) reviewed for free of accidents, hazards, supervision, and devices., in that: The facility failed to ensure precautionary interventions in place CR #1, who was a known fall risk that resulted in falls with serious injuries and multiple hospitalization. An Immediate Jeopardy (IJ) was identified on 1/16/2025. The IJ template was provided to the Administrator and DON on 1/16/2025 at 3:45pm. While the IJ was removed on 1/18/2025 at 4:29 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed facility residents who were fall risk at risk of serious harm and injury. 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-03-13 · 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 interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of eight residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure Resident #1 was not left unattended in her restroom for more than seven hours. The noncompliance was identified as PNC. The IJ began on 2/14/2024 and ended on 2/15/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for psychosocial harm, malnutrition, missed medications, pressure injury, fatigue, and death. Findings included: Record review of Resident #1's face sheet, dated 1/31/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included legal blindness, hypertension (high blood pressure), weight loss, neuropathy (group of diseases resulting from damaged or malfunctioning of nerves that causes…

  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 · Past Non-Compliance
• Immediate jeopardy · K2024-03-13 · tag F0602 — failed to protect residents from theft of their belongings — pattern
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure the resident was free from misappropriation of property for two of six residents (Resident #4 and Resident #5) and six of six (CR #2, CR #3, CR #6, CR #7, CR #8, and CR #9) closed records reviewed for misappropriation of property. 1. The facility failed to ensure that unknown staff did not misappropriate Resident #4, Resident #5, CR #2, CR #3, CR #6, CR #7, CR #8, and CR #9's controlled medications in November of 2023. 2. The facility failed to have a system in place to identify drug diversion of controlled substances. These failures could place residents at risk for misappropriation of medications and uncontrolled pain. The noncompliance was identified as PNC. The IJ began on 11/20/23 and ended on 11/21/2023. The facility had corrected the noncompliance before the survey began. Findings included: 1. Record review of Resident #4's face sheet, dated 2/23/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Kcited before2024-03-13 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for two of six residents (Resident #4 and Resident #5) and six of six (CR #2, CR #3, CR #6, CR #7, CR #8, and CR #9) closed records reviewed for pharmacy services. 1. The facility failed to ensure one former resident (CR #6) received the correct medication. CR #6's medication labels were switched. 2. The facility failed to ensure discontinued medication was discarded and controlled medication was destroyed according to standard protocols as nine medication packages were altered. These failures could place residents at risk for drug diversion, delay in medication administration, and receiving the wrong medications. The noncompliance was identified as PNC. The IJ began on 11/20/23 and ended on 11/21/2023.…

  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 · Past Non-Compliance
• Potential for harm · D2026-06-16 · tag F0559 — isolated
  Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
  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 had the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for 1 of 7 residents (Resident # 2) reviewed for resident rights.-The facility failed to ensure Resident #2, or her family member were provided with written notice before the resident was moved to a different room on 05/07/2026.This failure could place residents at risk for a decline in their well-being.The findings include:Record review of Resident #2's admission Record, dated 05/29/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included dementia (decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities) immunodeficiency (condition which the immune system is weakened or absent), systemic lupus erythematosus (chronic autoimmune disease where the immune system mistakenly…

  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 before2026-04-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse for 1 (Resident #1) of 5 residents reviewed for abuse.The facility failed to ensure Resident #2 was free from physical abuse when Resident #1 hit her leg on 3/16/26.This failure could place residents at risk of emotional distress, fear, decreased quality of life, and abuse.Findings included:Record review of Resident #1's face sheet dated 4/1/26 revealed a [AGE] year-old female who readmitted on [DATE]. Her diagnoses included hemiplegia and hemiparesis (hemiparesis is partial weakness on one side of the body, while hemiplegia is complete or near-complete paralysis on one side affecting right dominant side) following unspecified cerebrovascular disease (refers to a group of conditions that affect the blood vessels of the brain, often leading to stroke or other neurological impairments), dementia, mood disorder, bipolar disorder, psychotic disorder with hallucinations, and…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-01 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the interdisciplinary team reviewed and revised the resident's comprehensive care plan after each assessment for 1 (Resident #1) of 5 residents reviewed for care plan revisions.The facility failed to update and add interventions to Resident #1's care plan regarding physical behaviors toward other residents, including Resident #2.This failure could place residents at risk of injury.Findings included:Record review of Resident #1's face sheet dated 4/1/26 revealed a [AGE] year-old female who readmitted on [DATE]. Her diagnoses included hemiplegia and hemiparesis (hemiparesis is partial weakness on one side of the body, while hemiplegia is complete or near-complete paralysis on one side affecting right dominant side) following unspecified cerebrovascular disease (refers to a group of conditions that affect the blood vessels of the brain, often leading to stroke or other neurological impairments), dementia, mood disorder, bipolar disorder, psychotic…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-07-08 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to 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 disease and infection for 4 of 4 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for infection control, in that: - CNA J failed to wear PPE for EBP, when she provided incontinence care to Resident #1.- CNA H failed to sanitize her hands and change her gloves before putting a new brief on Resident #2 and the resident was on contact precautions for MRSA in the urine.- CNA M failed to wear PPE for EBP, when she provided incontinence care to Resident #3.- CNA G failed to wear PPE for EBP, when she provided incontinence care to Resident #4. These deficient practices could place residents at-risk for infection, sepsis, and hospitalization due to cross contamination. Findings included: Record review of Resident #1's undated face…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-30 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and interviews, the facility failed to ensure a resident has a right to personal privacy and confidentiality of his or her personal and medical records for 2 of 3 computers (LVN T and LVN C). The facility's computers were left open and unattended at the nurse's station with residents' personal medical information was visible to anyone who passed by on, 05/29/2025 while the user of the computer was on the hallway. The failure could place residents at risk of having their private information changed, viewed and not kept secure. Findings include: Observation on 05/29/2025 at 2:51pm reflected that LVN T and LVN C left the computers unlocked/opened and unsupervised, vaguely visible in an open area for resident and other individuals/guest of the facility passing by the nurse's station from inside of the nurses station and outside of the nurses station. Interview on 05/29/2025 at 2:52pm LVN T stated she briefly walked away from the computer and forgot to lock the computer before leaving the nurses station, because she was not going to be gone too long.…

  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 · D2025-05-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care was provided such care, consistent with professional standards of practice for 1 (Resident #26) of 2 residents reviewed for respiratory care. The facility failed to ensure Resident #26's oxygen tubing was changed every seven days as was ordered and per the facility's policy. The failure could place residents at risk of infection. Findings included: Record review of Resident #26's face sheet dated 5/28/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Hemiplegia (one sided weakness or paralysis) and Hemiparesis (weakness in one leg, arm, or side of the face) following Nontraumatic Intracerebral Hemorrhage affecting Right Non-dominant side. Record review of Resident #26's quarterly MDS dated [DATE] revealed a BIMS score of 15 that indicated cognition was intact. Record review of Resident #26's Order Summary Report with active…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-30 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 12% based on 3 errors out of 25 opportunities which involved 2 of 8 residents (Residents #39 and #30) and 2 of 7 staff (MA G and MA C) reviewed for medication administration. 1.The facility failed to ensure MA G did not administer Chewable Aspirin to Resident #39 instead of delayed release aspirin as ordered by the MD. 2. The facility failed to ensure MA C did not administer Divalproex 250 mg to Resident #30 after it was discontinued by the MD on 5/22/25. 3. The facility failed to ensure MA C did not administer one Vitamin D 1000 IU tablet to Resident #30 instead of two as ordered by the MD. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects and decline in health. Findings include: 1. Record review of Resident #39's face sheet, dated 5/29/25, revealed a [AGE]…

  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 before2025-05-30 · tag F0656 — failed to write and follow a full care plan — isolated
  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 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 2 of 12 Residents (CR #1 and Resident #26) reviewed for care plans. The facility failed to identify CR #1's diagnosis of Ventriculoperitoneal Shunt (a small plastic tube that is used to drain the cerebrospinal fluid from the brain into the space of the abdomen) in her care plan. The facility also failed to ensure that Resident #26's care plan included information regarding his oxygen that was ordered 5/7/25. The failure could place residents at risk of not having their needs met or inability of staff to identify a change of condition. Findings include: Record review of CR #1's Medication Review Report generated on 5/30/25 revealed CR #1 was admitted 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
• Potential for harm · D2025-05-30 · 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 interview and record review, the facility failed to ensure residents who were unable to carry out Activities of Daily Living received the necessary services to maintain grooming and personal hygiene for 2 (Residents #377 and #378) of 10 residents reviewed for Activities of Daily Living. The facility failed to provide Residents #377 and #378 with adequate services to maintain personal hygiene. This failure could place residents at risk of diminished quality of life, decreased self-esteem or skin breakdown. Findings included: Record review of Resident #377's face sheet dated 6/2/2024, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Myocardial Infarction (Heart Attack) and Muscle Weakness. Record review of Resident #377's admission MDS dated [DATE] revealed a BIMS score of 9 that indicated moderate cognitive impairment. Record review also revealed ADL performance code of 02 for bathing and showering that indicated Resident #377 required…

  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 · E2025-04-13 · tag F0550 — failed to protect resident dignity and rights — pattern
  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 observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 3 of 8 residents (Resident #1, Resident #2 and Resident #3) reviewed for resident rights. 1. The facility failed to ensure Resident #1's ileostomy (a surgical technique that uses small incisions and specialized instruments, including a laparoscope (a thin tube with a camera), to examine and treat conditions within the abdomen) bag was empty timely to avoid leakage. 2. The facility failed to ensure Resident #1 was cleaned immediately after his ileostomy bag leaked. 3. The facility failed to ensure that Licensed Vocational Nurse (LVN) A and certified nursing assistant (CNA) C maintained professionalism by speaking to and around Resident #1 with dignity and respect while providing ileostomy care. 4. The facility failed to ensure LVN A, LVN E, and LVN F were properly trained to maintain 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.

  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

$48,555 in federal fines across 2 penalties.

• $33,683 — penalty dated 2025-04-13
• $14,872 — penalty dated 2025-02-05

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 29 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $608K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX