Colonial Nursing & Rehabilitation 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.

52.7% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 73.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 23 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% 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 90 beds and averages 59.9 residents a day — about 67% occupied, or roughly 30 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 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 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 3.27 hrs/resident/day on weekends vs 3.60 on weekdays — 9% thinner on weekends. RN hours go from 0.36 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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.

23 citations, most serious first. The 13 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · K2024-12-27 · 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 observation, record review and interview the facility failed to ensure residents had the right to be free from abuse and neglect for 5 of 11 residents reviewed for abuse and neglect. (Resident #1 #2, #4, #5, and #8) 1. The facility failed to ensure Resident #2 was free from abuse after Resident #2 indicated MA B physically assaulted her on 11/9/24. The facility failed to address the abuse, report/investigate the allegations of abuse or suspend the alleged perpetrator. 2. The facility failed to provide assistance and supervision for Resident #1 between the hours of 12:20 am and 5:30 am on 6/2/24. Resident #1 rolled out of bed and was not checked on during this time. 3. The facility failed to ensure residents were free from abuse from Resident #7. a. Resident #7 was in Resident #8's room and was found touching Resident #8's genital area. Resident #8 had no pants on. b. Resident #7 pushed Resident #1 down on 10/3/24. c. Resident #7 choked Resident #8 on 10/4/24. d. Resident #7 had additional incidents of…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-12-27 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed implement their abuse policy to ensure residents had the right to be free from abuse and neglect, allegations were investigated, 7 of 11 residents reviewed for abuse and neglect. (Resident #1, #2, # 3, #4, #5, #7, and #8) 1. The facility failed to ensure Resident #2 was free from abuse after Resident #2 indicated MA B physically assaulted her on 11/9/24. The facility failed to address the abuse, report/investigate the allegations of abuse or suspend the alleged perpetrator. 2. The facility failed to provide assistance and supervision for Resident #1 between the hours of 12:20 am and 5:30 am on 6/2/24. Resident #1 rolled out of bed and was not checked on during this time. 3. The facility failed to ensure residents were free from abuse from Resident #7. a. Resident #7 was in Resident #8's room and was found touching Resident #8's genital area. Resident #8 had no pants on. This incident was not investigated, and no measures were put in place 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-12-27 · 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 a resident received adequate supervision and assistive devices to prevent accidents for 1 of 11 residents reviewed for accidents. (Resident #6) The facility failed to ensure CNA D prevented Resident #6 from failing during a mechanical lift transfer by transferring the resident alone. This facility failure could place residents at risk of injuries including lacerations and bruising to the forehead. Findings included: Record review of Resident #6's face sheet dated 12/16/24 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were paralysis on the left side due to a stroke, need for assistance with personal care, generalized muscle weakness, and lack of coordination. Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated his cognition was severely impaired. His functional limitation in range of motion was impaired on one side for the upper extremity (shoulder, elbow, wrist, 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-03-18 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
  Provide enough food/fluids to maintain a resident's health.
  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 maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 3 of 8 residents reviewed for nutritional status (Resident #9, #25, and #31). The facility failed to implement the RD's 02/21/2026 nutritional recommendations for Resident #9 who experienced a significant weight loss of 6.5% (6 lbs.) from 01/02/2026 to 02/10/2026. The facility failed to ensure the physician's orders included the amount of liquid nutritional supplement to be administered to Resident #25 and Resident #31. The facility failed to ensure the staff responsible for the delivery and administration of liquid nutritional supplements were clearly identified. These failures could place residents with weight loss at risk for malnourishment, further weight loss,…

  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 before2026-03-18 · 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, interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were complete and accurately documented for 4 of 6 residents (Residents #9, #25, #31,and #55) reviewed for medical records accuracy The facility failed to ensure the administration of nutritional supplements was documented in the clinical records for Resident #55, Resident # 9, Resident #25, and Resident #31. The facility failed to ensure physician orders included complete instructions for the administration of a liquid nutritional supplement (Med Pass) for Resident #9, Resident #25, Resident #31, and Resident #55. The facility failed to ensure the physician's orders for liquid nutritional supplements were transcribed into the MARs. These failures could place residents at risk for incomplete clinical records. Findings included: 1.Record review of a face sheet dated 03/17/2026 indicated Resident #55 was a [AGE] year-old female born 01/13/1934 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 · D2026-03-18 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect and promote the rights of each resident for 6 of 11 residents (Residents #14, #35, and 4 other unidentified Residents) reviewed for dignity and respect. CNA-A and CNA-B were observed eating their personal lunch in the secure unit dining area where Resident #14, Resident #35, and four unidentified Residents were sitting and waiting for their lunch to be served. This failure could place residents who reside in the secured unit of the facility at risk of not being treated with courtesy, consideration, and respect. Findings included: A record review of a face sheet dated 03/18/2026 indicated Resident #14 was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included Alzheimer's dementia and major depressive disorder. An elopement risk assessment completed on 02/14/2025 indicated Resident #14 was an elopement risk and was assigned placement on the secured unit of the facility. An annual MDS dated…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-18 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate MDS was completed for 1 of 5 residents (Resident #35) reviewed for MDS assessment accuracy. The facility failed to complete an MDS assessment that accurately reflected Resident #35's health status. This failure could place residents at risk of not receiving appropriate care and services to maintain the highest level of well-being. Findings included: A record review of a face sheet dated 03/17/2026 indicated Resident #35 was a [AGE] year-old female who re-admitted to the facility on [DATE] after being discharged from the hospital where she was treated for Influenza A, bilateral pneumonia, and sepsis (a life-threatening medical emergency caused by the body's response to an infection). A record review of an annual MDS with an assessment reference date (ARD) of 02/09/2026 indicated Resident #35 was coded for dehydration during the 7-day look-back period (the 7 days immediately preceding the ARD).Resident #35 had a BIMS score of 14…

  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 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 ensure all drugs and biological were stored in locked compartments under proper temperature controls and permitted only by authorized personnel to have access to the keys for 1 of 3 nurse medication storage carts (A Hall) reviewed for storage of medication and biologicals.The facility failed to ensure 15 tablets of APAP/Codeine 300-30mg (medication used for moderate to severe pain) was not, the medication expired on 11/01/25, and had been expired for 10 days, and were not removed from use.This failure could place residents at risk of adverse reactions to medications, misappropriation of medications, and not receiving therapeutic effects of medication.Findings include:Observation of the facility A Hall medication storage cart and interview with RN A on 11/10/25 at 06:45 p.m. revealed in second draw of the cart was an affixed lock box which revealed the following:-an individual medication card with 15 untouched tablets of APAP/Codeine 300-30mg with an expiration date of 11/01/25 and fill date of 11/01/24, 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-01-08 · 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 use the service of an RN for 8 consecutive hours 7 days a week. The facility did not have RN coverage on the following dates: 12/2/24 - 12/9/24, 12/13/24-12/18/24, 12/20/24-12/22/24, 12/25/24, and 12/28/24 - 1/6/2025. This failure has the potential to affect the residents in the facility and place them at risk of not having staff with advance care skills available to assist in their care needs. Finding included: Record review of the RN Coverage for months of December 2024 and January 2025 indicated there were no RN hours on the following dates: * 12/2/24 - 12/9/24 * 12/13/24-12/18/24 * 12/20/24-12/22/24 * 12/25/24 * 12/28/24 - 1/6/2025 During an interview on 1/6/2025 at 8:45 am, Administrator F, said the facility does not have a full time RN for coverage, she stated a possible negative outcome for not having an RN working for 8 hours/day would be that if something bad happened, the staff would not know what to do and would not have anyone to go to. During an interview on 1/7/2025 at 10:25 AM, the BOM stated the facility…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-01-08 · tag F0731 — widespread
  Request a waiver if it can't meet the nurse staffing requirements.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to designate a registered nurse (RN) to serve as the DON on a full-time basis since 11/3/2024 The facility did not have a DON from 11/3/2024 to currant date. This failure could place residents at risk of lack of nursing oversight and a higher level of care. Findings include: Record review of DON Coverage from Raw Punch Report dated 1/7/2025 indicated last day of DON coverage was 11/3/2024 with punch out time of 2:38pm with a total of 6.70 hours. During Entrance Conference interview on 1/6/2025 at 8:45 AM with the administrator F, she said they currently do not have a DON. ADM F said her first day of employment was 11/25/2024, and there was not a DON. Record Review of offer of employment for ADM F dated 11/16/2024, offer for employment for the administrator position at [facility] with effective start date of 11/25/2024. During an interview on 1/8/2025 at 2:09 p.m. the ADON, said she began employment on 11/11/2024 and there was not a DON at that time. Record review of letter dated 1/6/2025 at 6:50p.m. from ADM F stated: I am…

  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 · F2025-01-08 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen observed for kitchen sanitation. A 16 oz. bag of tortilla chips was opened and not re-sealed. DA A checked the sanitizing of the dish machine using quaternary ammonia test strips instead of chlorine test strips. The dish machine log January 2025 had been pre-filled with results for the noon check (01/06/25) when the noon meal had not occurred. The results indicated temperatures but no sanitizing conditions for any date. The dish machine log for December 2024 and January 2025 had blanks where washing temperatures and sanitizing results had not been documented. In the walk in cooler 2-46 oz. nectar thick iced teas, 1-46 oz. nectar thick orange juice, and 1-46 oz. honey thick water with lemon had been opened and not labeled with the open date. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations, interviews and record reviews on…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-01-08 · tag F0641 — pattern
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure accurate assessments were completed for 3 of 15 residents (Residents #16, #52, and #53) reviewed for accuracy of assessments. The facility failed to ensure Residents #16, #52, and #53's MDS assessment was accurately coded for Preadmission Screening and Resident Review (PASRR). These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.A review of Resident #16's face sheet for January 2025 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included bipolar disorder and depressive disorder. A review of Resident #16's PASRR Level 1 screening done 10/24/2024 indicated he now had a primary diagnosis of dementia and would not qualify for specialized services. A review of Resident #16's PASRR Evaluation done10/22/2020 indicated he was positive for mental illness but did not meet the PASRR definition 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-08 · 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 residents fed by enteral means received the appropriate treatment and services to prevent complications for the facility's only resident with an enteral device (Resident #34). The facility failed to ensure LVN D followed the facility's policy for administration of medications through an enteral tube (gastrostomy tube, G-Tube). This failure could place the resident at risk for clogging and/or damage of the gastrostomy tube and possible leakage of medications, formula, and/or water into the abdominal cavity. Findings include: A record review of a face sheet dated 01/08/2025 indicated Resident #34 was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included pharyngeal dysphagia (difficulty swallowing due to damage to the throat), erosive esophagitis (inflammation, irritation, or swelling of the lining of the esophagus), irritable bowel syndrome (intestinal disorder causing pain in the belly,…

  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

$247,572 in federal fines across 1 penalty.

• $247,572 — penalty dated 2024-12-27

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

Who owns this facility

CMS files one row per role, so the 3 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

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