Ashford Hall

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.

57.2% 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 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.60 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 57% 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 206 beds and averages 114.0 residents a day — about 55% occupied, or roughly 92 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 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 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 3.42 hrs/resident/day on weekends vs 3.82 on weekdays — 11% thinner on weekends. RN hours go from 0.85 to 0.94 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 77% is well above the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

35 citations, most serious first. The 16 most serious are shown; the remaining 19 are one tap away and print in full.

• Immediate jeopardy · Kcited before2024-08-10 · 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, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #2) of 6 residents reviewed for quality of care. The facility failed to identify and treat a wound to Resident #2's left great toe, prior to his visit to a local hospital on [DATE], where Resident #2 was found to have wound to his left great toe with osteomyelitis . Resident #2's left great toe was amputated on 06/18/24. An Immediate Jeopardy (IJ) situation was identified on 08/09/24. While the IJ was removed on 08/10/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. This failure could place residents at risk for delay in needed treatment and diminished quality of care. The findings included: Record review of Resident #2's face sheet,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-04-04 · 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 identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for 2 of 8 residents (Resident #1) reviewed for Quality of Care. Cumulative effects of LVN A's and MA V's individual failures to provide oversight of care delivery on 03/25/24, Resident #1 had an unwitnessed fall and sustained bruising, swelling, and an abrasion to the frontal scalp. The facility failed to implement interventions for Resident #1 identified as a fall risk on 12/05/22 to observe frequently and place in supervised area when out of bed (Start date 12/23/22). Resident #1 sustained unwitnessed falls in the dining room from the wheelchair on 03/14/24, 03/23/24, 03/28/24 and 04/03/24; a fall on 04/01/24 was documented as witnessed. Resident #1 had 46 documented falls since 12/05/22. The…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-04-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 2 of 8 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure adequate supervision for residents identified as a fall risk. Resident #1 sustained a skin tear to the right inner wrist on 03/14/24, a skin tear on the left inner wrist on 03/23/24, and sustained head trauma from an unwitnessed fall on 03/25/24. Resident #2 sustained blunt head trauma and a laceration above the left eyebrow from an unwitnessed fall on 03/09/24. The facility failed to implement effective care plan interventions for residents identified as a fall risk. An Immediate Jeopardy (IJ) was identified on 04/01/24. The IJ template was provided to the facility on [DATE] at 4:30 PM. While the IJ was lowered on 04/04/24, the facility remained out of compliance at a scope of Pattern and severity level of No actual harm with potential 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-03-22 · 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 residents 1 of 14 residents (Resident #1) were free from neglect. The facility failed to provide adequate wound care monitored by a physician for 30 days for Resident #1 with a Stage IV pressure sacral ulcer, skin tear of right knee, and pressure ulcer of left foot. The resident was sent to the hospital by the facility after with symptoms of lethargy, disoriented, anorexia and hypotensive. Resident was admitted to the hospital ICU as septic, had fluid overload with shortness of breath. The facility neglected Resident #1 daily wound care treatment and wound care management by physician services. These failures could place residents at risk for neglect due to facility not providing needed care and services. An Immediate Jeopardy (IJ) was identified on 3/20/2024. The ED was notified and provided with the IJ template on 3/20/2024 at 5:36 PM. While the Immediate Jeopardy was removed on 3/22/2024, the facility remained out of compliance at a scope 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-03-22 · 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 and record review, the facility failed to ensure residents received treatment and care according to professional standards of care and the care plan to prevent pressure ulcers or develop new ulcers for 1 of 14 residents (Resident #1) reviewed for pressure ulcers. The facility failed to provide adequate wound care monitored by a physician for 30 days for Resident #1 with a Stage IV pressure sacral ulcer, skin tear of right knee, and pressure ulcer of left foot. The resident was sent to the hospital by the facility after with symptoms of lethargy, disoriented, anorexia and hypotensive. Resident was admitted to the hospital ICU as septic, had fluid overload with shortness of breath. The facility failed to add the resident to wound care physicians list of patients for pressure ulcers. These failures could place residents at risk of development of additional pressure ulcers and further health decline. Findings included: Record review of resident's electronic medical record history and physical…

  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 before2026-03-24 · 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 observations, interviews, and record reviews, the facility failed to protect the residents' right to be free from abuse for three (Resident #2, Resident #3, and Resident #4) of five residents reviewed for abuse, in that: 1.) On 03/01/26 the facility failed to ensure that Resident #2 did not have her hair pulled by Resident # 1, resulting in Resident #2 screaming loudly in what sounded to facility staff like pain.2.) On 03/05/26 the facility failed to ensure that Resident #3 was not scratched on the face by Resident #1 resulting in redness.3.) On 03/10/26 the facility failed to ensure that Resident #4 was not verbally threatened, grabbed by the throat and her hair pulled by Resident #1 with no resulting injury. These failures could result in resident abuse and injuries.Findings include: Resident #1Review of Resident #1's Face Sheet with report date of 03/10/26, reflected she was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses in part including dementia (loss of memory,…

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

  Based on observation, interview and record review the facility failed to ensure the resident's environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of one maintenance room reviewed for accidents and hazards. The facility failed to ensure the door to the maintenance room located outside by the smoking area, which contained plugged power tools, harmful chemicals, and sharp tools, was secured. This failure placed residents at risk for injuries due to having access to an unsecured maintenance room.Findings include: In an observation on 4-7-2026 at 9:00 AM, the maintenance room door was left propped open and unattended by staff. The maintenance room was in a small building within 25 feet of the unlocked unalarmed dining room exit door and within 30 feet of the open smoking area. There were no barriers to block off access to the maintenance room door. There was an electric grinder, with the blade facing upward, plugged into an electrical outlet. The grinder was observed to turn…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-04-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the facility's one of one kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure food items, placed in the dry storage areas, were sealed and kept off the floor. 2. The facility failed to ensure food items placed in the refrigerator and/or freezer were dated, sealed and labeled appropriately. 3. The facility failed to ensure garbage receptacles in the kitchen had lids on them, when trash was in the containers, not being used. These failures could place residents at risk for food-borne illnesses.Findings include: In an observation on 4-7-2026 at 9:00 AM, revealed the facility's dry storage area had a few loose potato chips on the floor, 1 cart of approximately 20 bags of potato chips on the floor, one cheese puff, 14 boxes delivered with various food items sitting on the floor, and items that had fallen on the floor behind a large food shelf, were one six-pack of V-8 juice, one 13 oz…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-09 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 7 residents (Resident #3 and Resident #4) reviewed for resident assessments.The facility failed to accurately assess Resident #3's anticoagulant medication status.The facility failed to accurately assess Resident #4's anticoagulant medication status.These failures could place residents at risk of having an inaccurate care plans and inappropriate identification of care needs. Findings include:Record review of Resident #3's quarterly MDS, dated [DATE], revealed an [AGE] year-old female, who was readmitted to the facility on [DATE]. Resident #3 had a primary diagnosis which included sepsis (body has extreme response to infection). Other pertinent diagnoses included dementia (brain disease that alters brain function and causes a cognitive decline), cognitive communication deficit (impaired communication), atrial fibrillation (his is a heart condition that causes an irregular, often rapid…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-09 · 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 observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #11) reviewed for comprehensive person-centered care plans. The facility failed to develop a care plan to address Resident #11's nicotine dependence. This failure could place residents at risk of not receiving services to maintain their highest practicable physical, mental, and psychosocial well-being.Findings include:Record review of Resident #11's face sheet revealed a [AGE] year-old female. Resident #11 had a primary diagnosis which included attention and concentration deficit following cerebral infarction (cognitive impairment following a stroke). Other pertinent diagnoses included cognitive communication deficit…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure at the time each resident was admitted , the facility had physician orders for the resident's immediate care for 1 of 7 residents (Resident #12) review for physician orders upon admit. The facility failed to ensure Resident #12's hospital discharge order were followed.This failure could place residents at risk of not receiving care to meet the physical, mental, and psychosocial needs. Findings include: Record review of Resident #12's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #12 had a primary diagnosis of fracture of neck, subsequent encounter (fracture of neck that received treatment). Other pertinent diagnoses included chronic obstructive pulmonary disease (COPD, progressive lung disease making it difficult to breathe), chronic respiratory failure with hypoxia (lungs unable to bring oxygen to blood or get rid of carbon dioxide), difficulty in walking, and cognitive communication deficit…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-24 · 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 observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans.The facility failed to develop or revise care plan interventions for Resident #1 following three episodes of aggression towards other residents on 03/01/26, 03/05/26, and 03/10/26. This failure could have placed residents at risk of not having their needs identified and met.Findings include:Review of records noted that on: 1.) On 03/01/26 Resident #2 had her hair pulled by Resident # 1, resulting in Resident #2 screaming loudly in what sounded to facility staff like pain.2.) On 03/05/26 Resident #3 was scratched on the face by Resident #1 resulting in redness.3.) On 03/10/26 Resident #4…

  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 · D2026-03-04 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement the facility's own written abuse and neglect prevention policy and procedure for one (Resident # 1) of thirteen residents reviewed for abuse and neglect. The facility did not immediately notify Resident #1's representative of an allegation of sexual abuse by The Maintenance Director on 02/19/26, causing the family to learn of the allegation when Resident #1 called to tell them that the police were at the facility, attempting to speak with her about the allegation on 02/20/26. This failure could place residents at risk of their responsible parties not having knowledge of allegations of abuse or neglect, thereby not having the emotional or logistical support of their responsible parties during an investigation.Findings included: Review of the policy Abuse Investigation and Reporting, revised July 2017, reflected: [.] Role of the Administrator: 1. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown…

  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 · Ecited before2025-12-17 · 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 observations, interviews, and record reviews, the facility failed to protect the residents' right to be free from abuse for two (Resident #2 and Resident #3) of 5 residents reviewed for abuse, in that: 1.) On 11/03/25 the facility failed to ensure that Resident #2 did not have coffee thrown on him by Resident #4 resulting in redness to the face and chest which faded quickly and resolved without need for treatment. The nursing assessment completed the same day revealed no injury and no redness or other changes in skin assessment from baseline.2.) On 12/03/25 the facility failed to ensure that Resident #3 was not hit on the left side of the face/jaw with a closed fist by Resident #4 resulting in no injury. These failures could result in resident abuse and injuries.Findings include: Resident #2 Review of Resident #2's Face Sheet reflected he was a [AGE] year-old male readmitted to the facility on [DATE].Review of Resident #2's Quarterly MDS dated [DATE] reflected in part diagnoses including dementia,…

  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 · E2025-01-24 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide pharmaceutical services, including procedures that assured the accurate accountability of controlled narcotic drugs for 1 of 2 Residents (Resident #350) reviewed for pharmacy services. The facility failed to ensure that narcotic count sheet records were consistent with the remaining amount of narcotics. The facility failed to ensure that nursing staff signatures required for the narcotic count sheet were obtained and consistent with documentation of narcotics administered to Resident #350. These failures could place residents at risk for medication errors, potentially leading to overdose of narcotic pain medications, or diversion of narcotic pain medications. Findings included: Record review of Resident #350's face sheet dated, 01/22/2025, revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of Malignant neoplasm of cervix uteri (cervical cancer). Record review of Resident #350's admission MDS,…

  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 · D2025-01-24 · tag F0582 — isolated
  Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
  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 notification and receipt of Medicare Provider Non-Coverage letters (CMS 10123 or CMS 10055) which included information about their right to appeal were reviewed for Medicare Beneficiary Notification Review (Residents #71 and Resident #95). The facility failed to provide the Medicare Provider Non-Coverage letters to Resident #71 and Resident #95. This failure could place residents who receive Medicare Part A benefits at risk of not being fully informed of their right to appeal. Findings included: Record review of the document titled Beneficiary Notice - Resident discharged within the last 6 months, dated 08/24 through 12/2024 naming residents discharged from Medicare part A with benefit days remaining. Record review of the facility's Beneficiary Protection Notification indicated Resident #71's Medicare Part A skilled service start date was 08/24/2024 and last covered day of Part A service was 10/26/2024. Record review of 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.

  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

$301,255 in federal fines across 4 penalties.

• $15,935 — penalty dated 2026-03-04
• $6,144 — penalty dated 2024-09-24
• $22,391 — penalty dated 2024-08-10
• $256,785 — penalty dated 2024-03-22

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 28 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $720K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in TX