Legend Oaks Healthcare and Rehabilitation - Fort W

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

48.8% 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 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 61.4% 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 57 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 1.07 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 132 beds and averages 106.7 residents a day — about 81% occupied, or roughly 25 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.13 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 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 2.72 hrs/resident/day on weekends vs 3.30 on weekdays — 18% thinner on weekends. RN hours go from 0.55 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 68% 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 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.

26 citations, most serious first. The 16 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · K2026-06-13 · 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 each resident was free of any significant medication errors for 1 of 6 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1, who was diagnosed with Stage 4 renal carcinoma (kidney cancer), was administered his physician ordered oral chemotherapy medication, axitinib 3 mg bid, to treat his advanced kidney cancer. On 05/27/26 a computed tomography (CT) scan showed a 2 mm increase in the mass on Resident #1's right kidney. An Immediate Jeopardy (IJ) was identified on 06/12/26 at 4:16 p.m. and an IJ Template was provided to the Administrator at 4:50 p.m. While the IJ was removed on 06/13/26, the facility remained out of compliance at a scope of pattern with the severity level of no actual harm with potential for more than minimal harm that was not an immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at…

  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 · Jcited before2025-09-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1, who was a high risk for elopement for which he wore a WanderGuard device, was provided with adequate supervision to prevent him from exiting the building on 07/28/25. Despite the WanderGuard alarm sounding, RN A turned the alarm off without immediately going outside to determine if there was a resident elopement. The resident was found approximately nine hours after he went missing. He was found two miles away from the facility by the local police department following an extensive search. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 07/28/25 and ended on 07/29/25. The facility had corrected the noncompliance…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2024-10-08 · 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 to prevent accidents for 1 of 2 residents (Resident #2) reviewed for elopement. The facility failed to provide adequate supervision to Resident #2, who was aphasic and had right-sided hemiplegia, when the resident left the faciity on [DATE] without staff knowledge and made it approximately 1.5 miles from the facility with the assistance of a bystander. The resident was out of the facility for approximately two hours without staff knowledge, and he was located by his family who had placed a tracking device on his shoe. The non-compliance was identified as past non-compliance. The IJ began 09/15/24 and ended on 09/23/24. The facility corrected the non-compliance before surveyor's entrance. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] reflected the resident was a [AGE] year-old…

  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
• Actual harm · Hcited before2026-04-17 · 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 assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents.The facility failed to address the root cause of Resident #1's multiple falls, failed to implement therapy recommendations, and failed to implement interventions to prevent the resident from falling from his wheelchair from November 2025 to February 2026. On 12/02/25, Resident #1 fell from his wheelchair and sustained a laceration to the top of his left eyebrow and required four sutures on 02/07/26 when Resident #1 again fell from wheelchair and sustained an abrasion to the forehead and a hematoma of the scalp and during a scan Resident #1 was also found to have a subacute (condition that falls between sudden and long term/persistent) to chronic appearing nonunion fracture (broken bone that fails to heal) of the posterior left 11th rib. This failure could place residents at risk 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
• Actual harm · G2026-03-26 · 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 interviews, and record reviews, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 of 5 residents (Resident #1) reviewed for pressure ulcers. The facility failed to ensure Resident #1 did not develop a pressure wound to his left heel. This failure could place residents at risk of infection or a deterioration of their health.Findings included:Record review of Resident #1's admission MDS assessment , dated 02/06/26, reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included fracture of left upper arm, stroke affecting his left side, muscle weakness, and history of falls. He was discharged home on [DATE]. Resident #1's BIMS score was 14, indicating he was cognitively intact. His Functional Abilities assessment indicated he walked with the assistance of a…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-02-26 · 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 ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 5 residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse when Resident #2 pulled Resident #1 out of bed and hit him on 01/30/25. The noncompliance was identified as past noncompliance. The noncompliance began on 01/30/25 and ended on 01/30/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of being abused. Findings included: Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included heart failure, diabetes, stroke, and respiratory failure. The resident had a BIMS of 8, which indicated his cognition was moderately impaired. The MDS further reflected Resident #1 did not…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · D2026-06-30 · tag F0627 — isolated
  Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to allow a resident to remain in the facility when a resident exercises his or her right to appeal a transfer or discharge notice from the facility while the appeal is pending for 1 (Resident # 1) of 3 residents. The facility refused to allow Resident #1 to remain in the facility after her discharge date of 06/19/26 when they were notified on 06/15/26 that an appeal had been filed on her behalf. This failure could place residents at risk of not getting the opportunity to remain in a familiar homelike environment, getting the care and services required. Findings included: Record review of Resident #1's Discharge MDS assessment dated [DATE], revealed she was a [AGE] year-old female who was admitted to the facility on [DATE], and discharged on 06/19/26. Resident #1 had diagnoses that included: Diabetes Mellitus (high blood sugar), Morbid Obesity (overweight), Cerebral Infarction (stroke), Dysphagia (motor speech disorder), Muscle Wasting and Atrophy (loss of…

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

  Resident Rights Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · E2026-06-23 · tag F0813 — pattern
  Have a policy regarding use and storage of foods brought to residents by family and other visitors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. for 10 Rooms (Rooms 103, 108, 204, 213, 302,303, 305, 403, 408, and 616) of 20 rooms reviewed for safe food storage. The facility failed to monitor resident personal refrigerators in Rooms 103, 108, 204, 213, 302, 303, 305, 403, 408, and 616 to ensure they were clean, sanitary, and the temperature was monitored.This failure could place residents at risk of consuming unsanitary foods. Findings included: Observation on 06/23/26 at 9:25 A.M., the personal refrigerator located in room [ROOM NUMBER] revealed there was no log documenting the daily temperature checks of the refrigerator. Observation on 06/23/26 at 9:35 A.M., the personal refrigerator located in room [ROOM NUMBER] revealed there was no internal thermometer and no log posted documenting the daily temperature checks of the refrigerator.…

  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 · Ecited before2026-03-05 · 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, interviews and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.The facility failed to ensure items were properly covered and labeled in the walk in fridge, and fans used in the kitchen were free of grease and dust. These failures could place residents at risk of foodborne illness. Findings included: Observation on 03/03/26 at 8:48 AM in the kitchen revealed that a floor fan near the sink was running and pointed towards the steam table. Grease and dust were accumulated on the front grille of the fan. Observation on 03/03/26 at 8:53 AM in the walk in refrigerator, revealed the following:- one medium sized square container not covered completely. The plastic wrap was labeled and dated pudding 2/28- one medium sized square container not covered completely, holding an unknown item that looked like cheese sauce. The plastic wrap was dated 3/2 and had no label. Interview on 03/03/26 at 8:53 AM, the Dietary Manager said the containers should be…

  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 · E2026-03-05 · tag F0814 — failed to dispose of garbage properly — pattern
  Dispose of garbage and refuse properly.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters. (Dumpsters #1 and #2).1. The facility failed to ensure the lids and doors were completely shut on both dumpsters. 2. The facility failed to ensure trash, including used incontinent briefs and other garbage was not near dumpster #1.These failures could place residents at risk of an unsanitary environment and could attract pests, rodents and other animals. Findings included:Observation of the dumpster area on 03/03/26 at 8:58 AM revealed the following:- doors open on dumpster #1 and #2 exposing trash, - the lids on both dumpsters were open,- a clear trash bag with soiled incontinent briefs and other trash was lying partially underneath dumpster #1.Interview on 03/03/26 at 8:58 AM, the Dietary Manager stated the doors and lids should be closed, and trash picked up to keep rodents and bugs away. Interview on 03/03/26 at 2:16 PM, the Corporate Nurse stated she spoke with the Maintenance Supervisor who said he and housekeeping were responsible for maintaining the areas…

  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 · E2026-03-05 · tag F0842 — failed to keep accurate, complete medical records — pattern
  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, interviews and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, maintaining medical records on each resident that are complete and accurately documented for 1 of 6 (Resident #3) residents reviewed for clinical records.The facility failed to ensure Resident #3's TAR accurately indicated treatment provided or refusals on 01/06/26, 01/10/26, 01/20/26, 01/22/26, 01/24/26, and 01/27/26. This failure could place residents at risk of not receiving treatments and inaccuracy of their medical records. Findings included:Record review of Resident #3's Quarterly MDS assessment, dated 05/05/25, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #3's diagnoses included Diabetes Mellitus (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), Peripheral vascular disease (slow and progressive circulation disorder caused by…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-05 · 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 observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident 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 #4) reviewed for comprehensive care plans.The facility failed to develop a care plan for Resident #4's indwelling catheter.These failures placed residents at risk of infections and not receiving appropriate care.Findings included:Record review of Resident #4's MDS assessment, dated 01/07/26, reflected an [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had a BIMS score of 15 indicating his cognition was intact. Resident #4 required supervision or touching assistance with toileting. Resident #4's diagnoses included Benign Prostatic Hyperplasia without lower urinary tract (enlarged prostate) symptoms, Diabetes…

  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 · D2026-03-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  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 is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections based on the resident's comprehensive assessment for 1 of 3 residents (Resident #4) reviewed for urine incontinence/catheters. The facility failed to ensure Resident #4 had a physician order for the use and care of an indwelling catheter. This failure could place residents with catheters at risk of not receiving proper care and infections. Findings included: Record review of Resident #4's MDS assessment, dated 01/07/26, reflected an [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had a BIMS score of 15 indicating his cognition was intact. Resident #4 required supervision or touching assistance with toileting. Resident #4's diagnoses included Benign Prostatic Hyperplasia without lower urinary tract (enlarged prostate) symptoms, Diabetes Mellitus (high blood sugar),…

  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 · D2026-03-05 · 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 residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #83) reviewed for respiratory care. The facility failed to ensure Resident #83 had a physician order for oxygen treatment. This deficient practice could affect residents who received oxygen therapy from receiving inadequate oxygen support.Findings included:Record review of Resident #83's MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE]. Resident #83 had a BIMS of 15 indicating her cognition was intact. Her diagnoses included heart failure (heart muscle is unable to pump enough blood to meet the body's need for blood and oxygen), hypertension (high blood pressure), and chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe). Resident #83 had shortness of breath or trouble…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-05 · 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 assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 2 medication rooms (Station 2 medication room) reviewed for pharmacy services. The facility failed to remove expired medications from the Station 2 Medication Room, which included Famotidine, with an expiration date of 02/25, and Benzocaine 20% and Glucosamine, with an expiration date of 01/26. This failure could place residents at risk of receiving medications that were ineffective.Findings included: Observation on 03/04/26 at 12:36 PM of the Station 2 medication room with the ADON revealed 2 boxes of Famotidine 10 mg (medication to reduce stomach acid) with an expiration date of 02/25, Benzocaine 20% (topical numbing medication) with an expiration date of 01/26, and Glucosamine 500 mg (dietary supplement used to support joint health) with an expiration date of 01/26. Observation and interview on 03/04/26…

  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 · D2024-12-19 · tag F0693 — failed to provide proper feeding-tube care — isolated
  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 that residents who received nutrition by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #101) reviewed for enteral feeding. The facility failed to follow physician orders for Resident #101's enteral feeding tube to be flushed with 175 cc (mL) of water every 4 hours. This failure placed residents at risk of dehydration, aspiration pneumonia, and metabolic abnormalities. Findings included: Record review of Resident #101's admission Record dated 12/19/24 reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #101's quarterly MDS assessment dated [DATE] reflected his diagnoses included non-traumatic intracerebral hemorrhage in brain stem (brain bleed), respiratory failure, dysphasia (difficulty speaking) following other cerebrovascular disease (stroke), aphasia…

  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

“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

$77,433 in federal fines across 6 penalties.

• $11,850 — penalty dated 2026-06-13
• $18,150 — penalty dated 2026-03-05
• $19,135 — penalty dated 2026-03-05
• $10,361 — penalty dated 2025-09-11
• $9,110 — penalty dated 2025-02-26
• $8,827 — penalty dated 2024-10-08

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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 $862K 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX