Bay Ridge 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.

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at 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 58 beds and averages 40.8 residents a day — about 70% occupied, or roughly 17 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 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.23 hrs/resident/day on weekends vs 3.90 on weekdays — 17% thinner on weekends. RN hours go from 0.40 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 58% 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 unchanged from the previous inspection. 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.

34 citations, most serious first. The 18 most serious are shown; the remaining 16 are one tap away and print in full.

• Immediate jeopardy · J2026-06-26 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (CR #1) of 5 resident reviewed for notification of changes. RN A failed to notify CR #1's physician immediately when at approximately 6:30 am on [DATE], CR # 1 was delusional and looked pale yellowish. RN A failed to consult with CR #1's physician immediately for medical guidance when at approximately 8:00 am on [DATE], CR #1's oxygen saturation level was 84%. RN A waited until 12:30 pm to notify CR #1's physician regarding CR #1's change in condition after CR #1 became minimally responsive. On [DATE] at approximately 1:00 pm, CR #1 was sent to the hospital due to low oxygen saturation level. CR #1 was admitted to ICU with respiratory distress and hypotension. During ICU evaluation CR…

  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
• Immediate jeopardy · J2026-06-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (CR#1) of 5 resident reviewed for quality care. The facility failed to ensure CR #1 received treatment and care promptly when CR #1 experienced a change in condition of altered mental status and respiratory decline with low Oxygen saturation level. The facility failed to obtain an order for interventions including order to send CR#1 to hospital for further evaluation and treatment when CR #1's altered mental status was first identified around 6:30am on [DATE] and a decline in respiratory status with low oxygen saturation level identified around morning med pass on [DATE]. The facility failed to properly assess CR#1 or obtain vital signs after a change in condition of altered mental status and respiratory decline was identified. CR # 1 was not administered breathing…

  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 plan of correction
• Immediate jeopardy · Jcited before2025-11-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for 1 out of 3 residents (Resident #1) reviewed for adequate supervision.The facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent accidentsThis noncompliance was identified as Past Non-Compliance Immediate Jeopardy (IJ). The IJ began on 8/21/25 and ended on 8/31/25. The facility corrected the noncompliance by having implemented actions that corrected the non-compliance prior to surveyor entrance. This failure could expose residents living in the facility to safety and accident hazards.Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that include Anoxic Brain Damage (a brain injury that occurs when the brain is deprived of oxygen, which can lead to confusion, speech…

  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 before2024-03-07 · 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 the resident has the right to be free from abuse for 1 (Resident #1) of 5 residents reviewed for abuse. -The facility failed to ensure Resident #1 was free from abuse when CNA A allowed her significant other to verbally abuse Resident #1, allowed the significant other entry into the facility, and took him to Resident #1's room. The Significant other then threatened Resident #1 by pointing a gun at him. On 03/05/24 an Immediate Jeopardy (IJ) was identified. While the IJ template was removed on 03/07/24, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed residents at risk of physical harm, mental anguish or emotional distress, pain and/or death. The findings included: Record review of Resident #1's admission Record,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-03-07 · 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 remains as free of accident hazards for 1 (Resident #1) of 5 residents reviewed for quality of care. -The facility failed to provide a safe environment when CNA A allowed her significant other, who was armed with a pistol, entry into the facility's locked building, and access to Resident #1. -The facility failed to provide the Emergency Procedure - Workplace Aggression/Violence training. On 03/05/24 an Immediate Jeopardy (IJ) was identified. While the IJ template was removed on 03/07/24, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed residents at risk of physical harm, mental anguish or emotional distress, pain and/or death. The findings included: Record review of Resident #1's…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2022-09-25 · 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 interviews, observations, and record reviews the facility failed to ensure residents were free from abuse and neglect for 4 (Resident #7, #8, #23, and #38,) of 21 residents on the North Hall and 2 (Resident #30 and #35) of 17 residents on the South Hall. The Administrator and DON failed to provide necessary protection from staff member (TA K) who verbally and mentally Intimidated residents by yelling at them in angry tones, slammed resident doors to create fear, threatened residents with physical abuse, used retaliatory behavior in not providing timely care and invaded resident privacy by entering residents rooms without knocking or asking permission when female residents were undressing affecting residents' psycho social well-being causing fear and psycho social harm. On 09/23/22 at 5:10 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/25/22 at 12:30 pm, the facility remained out of compliance at a severity level of more than minimal harm that is not immediate jeopardy with…

  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 · K2022-09-25 · tag F0610 — failed to investigate and act on abuse reports — pattern
  Respond appropriately to all alleged violations.
  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 fully investigate, prevent, and correct an alleged violations of abuse and neglect for 4 (Resident #7, #8, #23, and #38,) of 21 on the North Hall and 2 (Resident #30 and #35) of 17 on the South Hall. The facility did not thoroughly investigate and correct an allegations of abuse that resulted in Resident #7, #8, #9, #23, 30, #35, and #38 causing psycho social harm and fearby TA K, while allowing him to continue working with residents in the facility. The Administrator and DON failed to provide residents necessary protection from staff member (TA K) who was threatening physical and verbal abuse in retaliation against residents who alleged incidents of his abusive behavior On 09/23/22 at 5:10 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/25/22 at 12:30 pm, the facility remained out of compliance at a severity level of more than minimal harm that is not immediate jeopardy with a scope of pattern due 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-03-22 · 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 interview and record review, the facility failed to ensure each resident was free from abuse for one (Resident #1) of fifty- one residents reviewed for abuse. The facility failed to prevent the AD from verbally abusing Resident #1. The AD made the statement where I come form snitches get stitches and end up in ditches. This failure could place 51 residents who participate in activities at risk of verbal abuse and decreased quality of life. Findings Included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were a cerebral infraction (area of tissue death to the brain), cognitive communication deficit (difficulty with thinking and using language), depression, and COPD (lung disease). Record review of Resident #1's MDS completed [DATE], revealed a BIMS (interview to determine a resident's mental status) score of 14 (cognitively intact). Record review of Resident #2's face sheet dated [DATE] revealed 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-05 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  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's discharge summary included an accurate reconciliation of all pre-discharge medications with post-discharge medication for 1 of 1 Residents reviewed for discharge medication reconciliation. The facility failed to complete an accurate reconciliation of medications for Resident #1 when he was discharged home on 1/31/2026. This failure could place residents at risk for discontinuity of care after being discharged from the facility to their home. Findings include:Record review of Resident #1's face sheet dated 2/2/2026 showed a [AGE] year old male was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (a medical condition where a patient experiences complete paralysis or weakness on the left side of the body because of a cerebral infarction, commonly known as a stroke, affecting the non-dominant hemisphere of the brain), bipolar…

  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 · E2025-11-25 · 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 interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 5 Residents (Resident #1 and Resident #2) reviewed for medical records accuracy. Resident #1's October 2025 MARs did not reflect documentation that Diclofenac three times a day was done as ordered. Resident #2's October 2025 MARs did not document Accu-check as done on 10/2/2025. This deficient practice could place residents at risk for errors in their care and treatment. Record review of Resident #1's admission face sheet, dated 10/24/2025, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included anemia (a condition were the body does not enough red blood cells), heart failure (when the heart muscle does not pump blood as well as it should), hyperlipidemia(high levels of fat in the blood), hemiplegia/hemiparesis, depression(mental health condition characterized 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 · Dcited before2025-11-25 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  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 that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately to the State Survey Agency for Resident #2. - The facility failed to investigate and report (within 2 hours or 24 hours) an incident involving an unwitnessed fall in which Resident #2 sustained a hematoma to the forehead and skin tear to the eyebrow. This failure could place residents at risk of falls not investigated to prevent abuse and neglect.Record review of Resident #2's admission face sheet, dated 10/24/2025, revealed Resident #2 was an [AGE] year-old female admitted on [DATE]. Resident #2's diagnoses included hypertension (high blood pressure), diabetes (high blood sugar), hyperlipidemia (high level of fat in the blood), malnutrition (when the body does not get enough calories, vitamin , minerals and protein), schizophrenia (a chronic mental health condition that impacts a person's thoughts,…

  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 · D2025-11-25 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure that residents were free of medication errors for 1 (Resident #1) of 5 residents reviewed for medication errors. Resident #1's October 2025 MARs did not reflect documentation that Diclofenac three times a day was done as ordered. This failure could place residents at risk of not getting their medications as ordered, which could result in residents not receiving the therapeutic benefits of the medication including increased pain and decreased quality of life.Record review of Resident #1's admission face sheet, dated 10/24/2025, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included anemia (a condition were the body does not enough red blood cells), heart failure (when the heart muscle does not pump blood as well as it should), hyperlipidemia(high levels of fat in the blood), hemiplegia/hemiparesis, depression(mental health condition characterized by feelings of sadness and loss of interest in…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-02-20 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person- centered care plan that included measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs identified in the comprehensive assessment for 3 of 12 residents reviewed for care plan accuracy (Residents #38, #17, #19), in that: 1. The facility failed to ensure the care plan for Resident #38's Hospice included a focus, goals, or interventions. 2. Facility failed to provide a care plan for Resident # 17's Dialysis. 3. Facility failed to document cerebral vascular accident affecting left side documented on Resident 19's care plan when they have right sided weakness. These failures placed residents at risk of not receiving needed services due to inaccurate comprehensive care plans. Findings include: Resident #38 Record review of Resident #38's face sheet revealed a [AGE] year-old female with admission date 2/22/24 and diagnoses including Hemiplegia and…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-08-07 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and record review the facility failed to coordinate the assessments with the pre admission screening and resident review (PASARR program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort which includes incorporating the recommendations from the PASRR level II determination and the PASARR evaluation report into a resident's assessment, care planning and transitions of care for 1 of 4 residents Resident #1 reviewed for PASARR. Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. The Facility failed to provide Resident #1 specialized services of PT, OT, and ST. Based on record review November 15, 2022 was the date listed in Simple LTC PASARR Portal. The facility failed to submit a NFSS request for nursing facility specialized services in the LTC Online Portal for Resident#1's OT, PT, and ST specialized services by a specific deadline. This failure could place residents at risk for 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-15 · tag F0802 — failed to prepare enough nourishing food — isolated
  Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and records reviewed, the facility failed to provide sufficient support personnel to carry out the functions of the food and nutrition service safely and effectively for 1 of 1 kitchen reviewed for dietary services. -The facility failed to provide sufficient dietary staffing for breakfast on 03/29/24. This failure could place residents at risk of not receiving meals at designated mealtimes and a diminished quality of life. The findings included: Observation and interview on 04/01/24 at 11:41 a.m., revealed Resident #3 was lying in bed. She said last Saturday, 03/30/24, or Friday, 03/29/24, they had kolaches and donuts for breakfast. She said she usually ate cereal for breakfast, but it was something she could eat and did not have any concerns about what was served. Observation and interview on 04/03/24 at 3:49 p.m., revealed Resident #6 was lying in bed. She said she had been feeling under the weather since she had returned from the hospital. She said the facility served donuts and kolaches last Friday, 03/29/24, for breakfast and she had enough to…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-15 · tag F0805 — failed to prepare food in a form residents can eat — isolated
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  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 each resident received and was provided food prepared in a form designed to meet individual needs for 2 (Resident #1 and Resident #2) of 5 residents reviewed for food preparation. -The facility failed to ensure Resident #1 and #2 received a pureed diet as ordered by the physician. This failure could place residents at risk for poor intake, unmet nutritional needs, choking, and aspiration (when food or drinks enter the lungs). The findings included: Record review of Resident #1's admission Record, dated 04/05/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included neuroleptic induced parkinsonism (condition where parkinsonian symptoms occur as a side effect of taking neuroleptic drugs), dysphagia (difficulty in swallowing) following unspecified cerebrovascular disease (group of conditions that affect blood flow and the blood vessels in the brain), dysphagia oropharyngeal phase (first stage…

  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 · Dcited before2024-03-22 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  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 failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, for one (Resident #1) of fifty- one residents reviewed for abuse. CNA B failed to report verbal abuse from the AD to Resident #1 to the Administrator. This failure could place 51 residents who participate in activities at risk of verbal abuse and decreased quality of life. Findings Included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were a cerebral infraction (area of tissue death to the brain), cognitive communication deficit (difficulty with thinking and using language), depression, and COPD (lung disease). Record review of Resident #1's MDS completed [DATE], revealed a BIMS (interview to determine 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-03-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #1) of 5 residents reviewed for ADLs. -The facility failed to ensure Resident #1 received timely incontinence care. This failure could put residents at risk for discomfort, infection, and dignity issues. The findings included: Record review of Resident #1's admission Record, dated 03/13/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included cerebral infarction (stroke), muscle weakness, need for assistance with personal care, contracture (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) left shoulder, and contracture of muscle, multiple sites. Record review of Resident #1's Quarterly MDS assessment, dated 02/29/24,…

  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

$54,678 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $36,624 — penalty dated 2026-06-26
• $8,021 — penalty dated 2024-01-25
• $10,033 — penalty dated 2024-01-25
• Medicare payment denial — starting 2024-04-05 for 10 days

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

Part of a chain

This home belongs to NEXION HEALTH — 51 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 11 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

About 86% 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 $136K 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