Lake Lodge Nursing & Rehabilitation

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 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 140 beds and averages 69.8 residents a day — about 50% occupied, or roughly 70 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 3.26 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.77 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 2.99 hrs/resident/day on weekends vs 3.37 on weekdays — 11% thinner on weekends. RN hours go from 0.27 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 93% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

Inspection deficiencies

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

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

29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.

• Immediate jeopardy · J2024-06-06 · tag F0777 — isolated
  Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide radiology or other diagnostic services to meet the needs of its residents in a timely manner for 1 (Resident #1) of 3 residents reviewed for radiology services. The facility failed to follow up on Resident #1's x-ray results in a timely manner. The facility failed to follow up on x-ray results that revealed a fracture of the right tibial plateau. Resident #1 was sent to hospital on [DATE] at 10:10 am. The noncompliance was identified at PNC. The Immediate Jeopardy (IJ) began on 05/12/2024 and ended on 05/15/2024. The facility had corrected the noncompliance before the survey began. These failures resulted in delayed diagnosis, medical treatment, and hospitalization. Findings included: Review of Resident #1's admission record, dated 06/05/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score…

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

  Administration Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2024-02-29 · 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 review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Residents #1) reviewed for abuse. The facility failed to protect Residents #1 from neglect when they failed to provide the necessary care devices to prevent injury from a fall. Resident #1 had a history of subdural hemorrhage with brain injury and a previous order for a fall mat. The CNA was aware the fall mat was missing and Resident #1 experienced convulsions/seizures resulting in a fall. Resident #1 sustained a skin tear from the fall. These failures could place residents at risk of abuse and neglect, serious injury, serious harm, serious impairment, pain, mental anguish, or death. On 02/28/24 at 3:38 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/29/24 at 3:52 PM, the facility remained in compliance at a severity level of no harm and a scope of isolated 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
• Immediate jeopardy · J2024-02-29 · 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 interview and record review the facility failed to ensure the resident environment remained free of accidents hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 8 residents reviewed for accidents hazards. The facility failed to protect Residents #1 from accidents when they failed to provide the necessary care devices to prevent injury from a fall. Resident #1 had a history of subdural hemorrhage with brain injury and a previous order for a fall mat. The CNA was aware the fall mat was missing and Resident #1 experienced convulsions/seizures resulting in a fall. Resident #1 sustained a skin tear from the fall. This failure could affect 8 Residents at the facility that received fall precautions and interventions resulting in serious harm and injuries. On 02/28/24 at 3:38 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/29/24 at 3:52 PM, the facility remained in compliance at a severity level of no harm and 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
• Potential for harm · Dcited before2026-03-31 · 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 staff failed to ensure staff reported potential use of medication not provided by the facility to the ADM and DON for 1 of 5 (Resident #1) reviewed for quality of care.CNA B failed to report Resident #1 told her he had been taking medication for weight loss provided by family.This failure could place residents at risk of adverse effects to medications or medication interactions, that can lead to residents not meeting their highest practicable physical, mental, and psychosocial needs.Findings included:Record review of Resident #1's face sheet revealed an [AGE] year-old male admitted with a primary diagnosis of acute respiratory failure (lungs cannot get enough oxygen in blood). Other pertinent diagnoses included anxiety disorder (excessive fear or worry), acute on chronic systolic congestive heart failure (body cannot pump enough blood to heart), acute pulmonary edema (fluid buildup in lungs), type 2 diabetes mellitus (body cannot produce enough insulin 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-11 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 08 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8,) of 12 residents reviewed for infection control. The facility failed on 03/11/26 to ensure infection control procedures were followed when the MA failed to sanitize the wrist blood pressure cuff between each resident when she obtained blood pressure readings.This failure could place residents at risk of infection. Findings included: Record review of Resident #1's face sheet, dated 03/11/26 reflected he was a [AGE] year-old male who was admitted on [DATE] and diagnosed with Parkinson (progressive neurological disorder causing movement problems), unspecified, tremor (an involuntary, rhythmic shaking…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-01-08 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure a Registered Nurse was on duty in the facility for a minimum of eight consecutive hours a day, seven days a week, for 6 of 26 weekend days (11/01/2025, 11/02/2025, 11/15/2025, 11/16/2025, 11/29/2025, 11/30/2025) reviewed for RN coverage. The facility failed to have RN coverage on the following dates in 2025:- 11/01/2025, 11/02/2025, 11/15/2025, 11/16/2025, 11/29/2025, 11/30/2025 This failure could place residents at risk of not having their nursing and medical needs met, and other direct care staff not receiving sufficient oversight.Findings included: Review of an undated excel file, covering the RN time stamp hours for weekend dates of the first fiscal quarter of 2026 reflected insufficient RN coverage on the following dates of 2025. - 11/01/2025, 11/02/2025, 11/15/2025, 11/16/2025, 11/29/2025, 11/30/2025During an interview on 1/08/2026 at 2:56 PM, the DON revealed she was responsible for RN weekend schedules. She said RNs were scheduled to work 6:00 PM - 6:00 AM during the weekends and the RNs would take a break…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-08 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to provide safe and secured storage of drugs and biologicals by not keeping medication in locked compartments, for 1 of 5 carts reviewed for medication storage in that:LVN A failed to lock treatment cart while not in use. This failure could result in physical injuries to residents; drug diversions, ingestion of medications causing adverse effects and violation of HIPAA (Health Insurance Portability and Accountability Act). Findings includedIn an observation on 1/6/2026 at 9:10am, treatment cart in hall 400 was unlocked when not in use. Inside treatment cart was Resident #1's silver sulfa cream, wound supplies, 2 pairs of scissors, and 2 bottles of wound cleaning liquid. Treatment cart was unlocked and not in use for 5 minutes.In an interview on 1/6/2026 at 9:15am with treatment nurse. She stated medication cart and treatment cart should be locked at all times due to risk of injuries to residents and HIPAA violation. She stated a resident could have gotten ahold of would cleaning liquid and caused chemical…

  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 before2025-09-04 · tag F0583 — failed to protect personal privacy — pattern
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record reviews, the facility failed to protect residents' right to personal privacy and confidentiality of his or her personal and medical records for 10 of 74 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10) reviewed for confidentiality of records. CNA A provided a list containing residents' names and medical appointment details to Resident #1. This failure could place residents at risk for psychosocial damage, emotional damage and potential fraudulent. Findings included:Record review of facility's incident investigation, dated 8/4/2025, revealed CNA A, who was the facility's transport person, gave a list of residents' names and their appointments to Resident #1. The list included the following information_Resident #2's Magnetic Resonance Imaging (MRI) appointment._Resident #3's orthopedic (bone & joint specialist) appointment._Resident #4's podiatry (foot specialist) appointment._Resident #5's orthopedic appointment._Resident #6's podiatry appointment._Resident #7'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
• Potential for harm · Dcited before2025-04-07 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 Residents (Resident #1) reviewed for infection control. 1. The facility failed to ensure CNA B used the required PPE for Resident #1, who was on enhanced barrier precautions due to her wound, and indwelling foley catheter, while assisting LVN A with Resident #1's wound care and getting Resident#1 dressed on 04/07/25. 2. The facility failed to ensure LVN A used the required PPE for Resident #1, who was on enhanced barrier precautions due to her wound, and indwelling foley catheter, while performing wound care for Resident #1on 04/07/25. 3. The facility failed to ensure LVN A performed hand hygiene between glove changes when she went from dirty to clean during incontinence care for Resident #1. 4. 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-11 · 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 report an alleged violation involving neglect, misappropriation of resident property, exploitation, or mistreatment, and does not result in serious bodily injury not later than 24 hours to the administrator of the facility and to other officials, including to the State survey and certification agency and adult protective services in accordance with State law for one (Resident #1) of four residents reviewed for misappropriation of resident's property and exploitation. The Housekeeper failed to report to the facility administrator who was the abuse coordinator that Resident #1 was missing money totaling $90 when Resident #1 first reported the missing money weeks prior to 03/11/25. This failure could place residents at risk of not receiving timely investigations and reporting of misappropriation of resident's property and exploitation. Findings included: Review of Resident #1's admission record dated 03/11/25 revealed a [AGE] year-old female with an…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-25 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the resident had a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living for three of 13 residents (Residents #1, #2 and #3) reviewed for environmental concerns. 1. The facility failed to ensure Resident #1's restroom was cleaned daily. 2. The facility failed to ensure Residents #1, #2 and #3's restroom had hot water. These failures could place residents at risk for a decreased quality of life. Findings include: 1. Record review of Resident #1's, undated, admission Record revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Chronic obstructive Pulmonary Disease with (Acute) Exacerbation (is a sudden worsening of COPD symptoms, including shortness of breath, cough, and/or an increase in the volume and/or purulence of the sputum [A mixture of saliva and mucus produced by the lungs as a result 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 date of correction
• Potential for harm · E2024-10-17 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY FACILITY Resident Council 10/16/24 09:57 AM Omb TC: [NAME] Omb: [NAME] (volunteer) Residents in attendance: [NAME]- RC President [NAME] [NAME] [NAME] [NAME] [NAME] [NAME] [NAME] [NAME] [NAME] (late arrival) Res says staff have not responded to requests/recommendations from residents or council meetings/ same req each month; per Adm res have rights unless it conflicts with her; res state no reasons being given for not responding to , when res go back they are told someone has dropped the ball and start over from sq one Grievance Rep is ADM and she is not responding per residents (per Omb grievance process is supposed to be started with SW) wait times for care 30-45 mins on average; still issues with staff spending /focusing on personal conversations and on personal cell phones during time providing res care; staff still on phones/using ear buds when providing care to res res state not always getting snacks when asked for; feel staff pick and choose what res get snacks (mostly 6p-6a shift that are choosy who they…

  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 · E2024-10-17 · tag F0700 — pattern
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  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 review the risks and benefits of bed rails and enabler/grab bars (smaller bars used by the person in bed to reposition themselves), with the resident or resident representative, conduct a safety assessment, and obtain informed consent prior to installation for two (Residents #3 and #63) of six residents observed for bed rails/enabler bars. The facility failed to have an informed consent, assessment of the resident for risk of entrapment, or care planning for the safe use of bed rails/enabler bars for Residents #3 and #63. This failure could affect residents who used bed rails/enabler bars at risk of the resident/responsible party not being aware of the risks, informed consent not being obtained from the resident or responsible party, and care plan not being properly documented. Findings included: Resident #3: Observation of Resident #3 on 10/15/2024 at 9:20 AM revealed the resident asleep in a bed that was pushed against the wall of the room along 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

“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

$33,845 in federal fines across 2 penalties.

• $15,956 — penalty dated 2024-05-23
• $17,889 — penalty dated 2024-02-29

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 CREATIVE SOLUTIONS IN HEALTHCARE — 149 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

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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 75% 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. 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