Sunset Valley Rehabilitation and 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 0.37 therapist hours per resident per day in 2026Q1 — more than 64% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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 80 beds and averages 42.7 residents a day — about 53% occupied, or roughly 37 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 3.08 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 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 2.90 hrs/resident/day on weekends vs 3.15 on weekdays — 8% thinner on weekends. RN hours go from 0.33 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% is well above the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

38 citations, most serious first. The 14 most serious are shown; the remaining 24 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-08-26 · 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 immediately inform the resident's physician and resident representative of a significant change in the residents' physical status and the need to significantly alter the resident's treatment for 1 of 4 residents (Resident #1) reviewed for Change in Condition. The facility failed to correctly notify the physician and resident representative of the extent of one facility-acquired Stage IV pressure injury for Resident #1, thus delaying proper treatment for 2 days. An Immediate Jeopardy (IJ) was identified on 08/22/2024. The IJ Template was provided to the facility on [DATE] at 4:53PM. While the IJ was removed on 08/26/2024, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy and a scope of Isolated due to the need for implementation of corrective measures and the effectiveness of its corrective plan. This failure could place residents at risk of not having their…

  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
• Immediate jeopardy · Jcited before2024-08-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident # 1) reviewed for contractures. The facility did not prevent the development of one facility-acquired Stage IV, exposed tendon, pressure injury for Resident #1. This failure could place residents at risk for worsening of an ulcer, infection, and a decreased quality of life. An Immediate Jeopardy (IJ) was identified on 08/04/2024. The IJ Template was provided to the facility on [DATE] at 4:00PM. While the IJ was removed on 08/06/2024, the facility remained out of compliance at a level of more than minimal harm and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy and a scope of Isolated due to the need for implementation of corrective measures…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that the resident with pressure ulcers receives appropriate treatment/services received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers, for 1 closed record (CR #1) of 2 residents reviewed for pressure ulcers. CR #1 acquired a pressure ulcer to her coccyx that deteriorated to a stage IV wound while residing at the facility. The facility failed to have NP wound care consultant assess CR #1 while on isolation for COVID. The facility delayed wound care interventions for CR #1 for 5 days after identifying coccyx wound had a foul odor and dead tissue inside the wound bed. The facility failed to obtain a wound care culture for CR #1 after wound had a foul odor and wound bed worsening. The facility failed to provide CR #1 with proper nutrition and supplements to aid in wound healing. These failures could place residents with pressure ulcers at…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  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 interview, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, unless the resident's clinical condition demonstrated that this was not possible, for one closed record (CR# 1) of 1 resident reviewed for weight loss. CR #1 had a significant weight loss of 57.7 pounds, a 14.7% body mass loss in less than 6 months, January 2023 to June 2023. The facility failed to develop and implement interventions to prevent weight loss and improve wound healing. This failure affected 1 discharged resident and placed other residents at risk for weight loss, wound healing and a decline in health. Findings included: Record review of CR's #1's Face Sheet indicated a [AGE] year-old female originally admitted to facility on 5/31/2012. CR #1 was transferred to the hospital on 5/7/23. Her primary diagnoses included primary generalized (osteo) arthritis (degenerative disease of the joints that worsens over time); major depressive disorder, moderate intellectual…

  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 · E2026-02-26 · tag F0576 — pattern
  Ensure residents have reasonable access to and privacy in their use of communication methods.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, and record review, the facility failed to ensure residents had the right to send and receive mail for 11 of 11 confidential residents reviewed for right to communication. The facility failed to ensure residents received their mail on the weekend. This failure could put residents in the facility who receive mail at risk for not receiving mail in a timely manner that could result in a decline in the residents' psychosocial well-being and quality of life.Findings included: During a confidential group interview at an undisclosed date and time, 11 of 11 residents said mail was not being distributed on the weekend. They indicated they were unsure why mail was not delivered by the weekend staff. They indicated they had never received mail on the weekend, nor had they ever been asked at their regular monthly meetings about receiving mail on the weekend. They stated they thought that was not a service offered by the facility. In an interview on 02/26/2026 at 09:17 a.m. AD stated she passes out the resident's mail to them Monday through Friday. She stated the post office…

  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 · E2026-02-26 · tag F0585 — failed to handle grievances — pattern
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  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 information to residents and their representatives on their rights related to filing grievances or concerns for 11 of 11 confidential residents. The facility failed to ensure 11 confidential residents were provided with access to the grievance form and provided the procedure for how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included: Interviews during an undisclosed date and time, 11 confidential residents stated they did not have access to the Grievance form, they did not know they could file a grievance anonymously, the grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the grievance procedure in prominent locations. The confidential Residents also said they did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. Record review of the facility Grievance policy revised date 12/2023;…

  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 · Ecited before2026-02-26 · 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 a resident maintained acceptable parameters of nutritional status, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise, for 1 (Resident #46) of 15 residents reviewed for nutrition. The facility failed to implement monitoring and interventions to ensure that Resident #46 did not have a significant weight loss of 30.3 pounds, a 16.5% body weight loss, between 01/02/26 and 02/03/26. This failure could place residents at risk for decreased nutritional status, malnutrition, and a decline in health.Findings Included:Record review of Resident #46's face sheet dated 02/26/26 reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #46 had diagnoses with included: end stage renal disease (the final stage of kidney failure), alcoholic cirrhosis of the liver (alcohol-associated liver disease), Type II Diabetes Mellitus (a disease resulting 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-02-26 · tag F0803 — failed to meet residents' dietary needs — pattern
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  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 that the menus were followed for 2 of 2 meals (lunch meals) and for 2 of 2 pureed food trays (on 2/24/26 and 2/25/26) reviewed for meal accuracy, in that: On 2/24/26, [NAME] E failed to serve the correct portion size of braised Swiss steak and mashed potatoes according to the prepared menu for lunch for 40 residents. 2. On 2/24/26, [NAME] E failed to follow the recipe for Braised Swiss Steak, causing dish to be served in the form of a loose meat in a liquid soup instead of a patty topped with gravy. 3. [NAME] E failed to include the wheat roll on the pureed food trays served during lunch on 2/24/26 and [NAME] D failed to include the cornbread on the pureed food trays served during lunch on 2/25/26. These failures could affect residents who received food from the kitchen by contributing to dissatisfaction, poor intake, and/or weight loss.The findings included: Record review of the menu for the lunch meal on 2/24/26 at 11:30 AM revealed, Braised Swiss Steak, Mashed Potatoes, Steamed Broccoli, Wheat Roll,…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-02-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (Kitchen A) reviewed for dietary services. The facility failed to ensure no expired food items were in the kitchen. 2. Toxic items were not stored in a manner to prevent contamination of foods and food contact equipment (hand sanitizer). 3. Time Temperature Controlled for Safety cold foods were not maintained at 41 F or below (milk/supplements) due to refrigerators not functioning properly. 4. Foods were held for use beyond the manufacturers recommended Best if used by/ Best by dates (kitchen storage). 5. Clean plates and bowls were stored facing upward. These failures could place residents at risk for food contamination and foodborne illness. The findings included: On 2/24/26 at 9:44 AM an initial kitchen observation tour began. The tour ended at 10:30 AM and revealed the following: The external thermometer of Refrigerator B indicated an internal temperature of 45 F. The contents…

  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 before2026-02-26 · 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 ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 2 medication cart (Hall D medication cart) reviewed for storage of drugs.The Facility failed to provide change direction labels for Resident #15's medication package of hydroxyzine (hydroxyzine is an antihistamine that reduces symptoms caused by allergies) which had medication order change from as needed every 6 hours to 10 mg twice a day. This failure could place residents at risk of medication misuse and diversion.The findings were:Record review of Resident #15's physician orders, dated 02/26/2026, revealed an order for hydroxyzine 10 mg give 1 tab by mouth twice a day with a start date of 01/29/2026 and no end date. Observation on 02/25/2026 at 08:32 a.m. revealed a package in the Hall D medication cart contained medication for Resident #15 with a label for 10 mg of hydroxyzine, and instructions to give 1 tab by mouth every 6 hours as needed. MA administered 10 mg of hydroxyzine to Resident…

  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 · Dcited before2026-02-26 · 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 1 resident (Resident #52) reviewed for infection control. LVN C did not wash her hands after removing PPE and exiting Resident #52's room. These failures could place residents at risk for cross contamination and infection. Findings included: Record review of the admission record for Resident #52 undated, revealed a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: sepsis (infection which can result in widespread inflammation and damage to vital organs), epilepsy (seizure disorder), diabetes (high blood sugar) and quadriplegia (partial or complete loss of function in all four limbs and torso). During an observation on 0/24/2026 at 04:46p.m., LVN C was…

  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 · D2026-02-26 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolated
  Have policies on smoking.
  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 follow their own established smoking policy for 1 of 2 residents reviewed for smoking. (Resident #29) The facility failed to ensure Resident #29 followed the smoking policy and did not have smoking supplies (cigarettes and lighter) in their room. This failure could place residents at risk of injury or harm. The findings included: Review of Resident #29's face sheet, dated 2/25/26, revealed a [AGE] year-old male with an initial admission date of 1/28/20 with the following diagnoses: Acute Respiratory Failure with Hypoxia (inability for the lungs to adequately transfer oxygen to the blood), Unspecified Dementia, Unspecified Severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (memory loss, inability to think/plan), Epilepsy, unspecified, intractable, without status epilepticus (neurological disorder characterized by unprovoked seizures), personal history of Transient Ischemic Attack, and cerebral…

  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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-22 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the comprehensive assessment and plan of care for 1 (Resident #1) of 5 residents reviewed for behavioral health services. The facility failed to ensure Resident #1's comprehensive care plan included goals and interventions addressing her documented history of aggression, refusal of care and the use of psychotropic medication for behavioral management related to her behavioral diagnosis.This failure could place residents at risk for diminished quality of life due to the lack of treatment and prevention to maintain resident safety. Findings included:Record review of Resident #1's face sheet dated 12/22/2025 revealed she was a [AGE] year-old female resident originally admitted to the facility on [DATE] with diagnoses to include but not limited to Alzheimer's disease with late onset (memory…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-01-15 · 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

  Based on observations, interviews, 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 3 of 37 residents (Resident #1, Resident #2, and Resident #3) reviewed for infection control. The facility failed to ensure proper hand hygiene techniques were practiced while feeding dependent residents (Residents #1, #2 and #3) during the luncheon service. This failure could place residents at risk of the spread of communicable diseases and infections and a diminished quality of life. Findings included: An observation of the luncheon service on 01/15/2025 at 11:55AM revealed CNA A, CNA B and LVN C feeding residents who required full assistance while eating. CNA A got up from the table where she was feeding Resident #1 to move her wheelchair closer to the table. She sat back down and before continuing to feed Resident #1, ran her hands through her hair to move her hair off her…

  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

“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

$44,434 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $15,944 — penalty dated 2024-08-26
• $28,490 — penalty dated 2023-08-29
• Medicare payment denial — starting 2023-09-30 for 1 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 PARAMOUNT HEALTHCARE CONSULTANTS — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

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

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

Follow the money — this home’s finances

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

About 78% 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 $218K 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