Castle Pines Health & 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.

49.7% 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 150 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 49.1% 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 55 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 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 24% 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 120 beds and averages 93.1 residents a day — about 78% occupied, or roughly 27 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.35 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 2.13 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 2.87 hrs/resident/day on weekends vs 3.54 on weekdays — 19% thinner on weekends. RN hours go from 0.20 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

19 citations, most serious first. The 13 most serious are shown; the remaining 6 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision to prevent elopement for 1 of 1 (Resident #1) resident reviewed for supervision. The facility failed to keep Resident #1 in a safe environment to prevent an elopement on 3/23/26 when he walked out the front door of the facility.The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 3/23/26 and ended on 3/24/26. The facility corrected the non-compliance before surveyor's entrance.This failure could place residents at risk of not being properly supervised resulting in injury or death.Findings included: Record review of the electronic face sheet indicated Resident #1 was a [AGE] year old male originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnosis that included: malignant neoplasm of the brain (brain cancer), hyper lipidemia (high cholesterol), seizures, carcinoma (cancer) in bronchus and lung, nicotine…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2024-03-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #13) reviewed for accidents and hazards. The facility failed to ensure Resident #13 was provided with adequate supervision to prevent her from falling off the mechanical lift of the facility van on 02/28/24. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/28/24 and ended on 03/05/24. The facility corrected the non-compliance before survey began. This failure could place residents at risk of harm and serious injuries due to lack of supervision and failure to follow protocols. Findings included: Record review of Resident #13's Face sheet undated revealed she was admitted to the facility on [DATE]. Resident #13 was a [AGE] year-old female admitted with diagnosis of anemia (low red blood cells), end stage renal…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2023-09-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the residents environment remained free from accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 3 of 5 residents (Residents #4, #8, and #9) reviewed for accidents, hazards, and supervision. 1.The facility failed to adequately supervise Resident #4 when being transferred. Resident #4 sustained a fracture of the proximal tibia (broken bone below the knee) when the Hoyer lift tipped over while being transferred with a Hoyer lift device (a mobility device with a U-shaped base and an overhead horizontal bar with hooks on top. A sling suspended by loops or metal clips attached to the overhead bar with hooks. The lift is used to lift and transport people who cannot safely walk or put weight on either leg) by CNA A on 09/07/23. 2. The facility failed to ensure that on 9/26/23 at 10:26 am CNA B and CNA C opened the legs to stabilize base of Hoyer lift during…

  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 · E2025-05-20 · 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 observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 6 sampled residents (Resident #24 and Resident #44) and one of one dining rooms reviewed for environment. The facility failed to ensure the dining room was without excessive noise levels during meals for Resident #24, Resident #44 and other residents in the dining room. This failure could place residents at risk for diminished quality of life due to the lack of an enjoyable dining experience. Findings included: Record review of Resident #24's face sheet, dated 05/19/2025, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Dementia (loss of memory, language, problem-solving, and other thinking abilities that were severe enough to interfere with daily life), Chronic obstructive pulmonary disease also known as COPD (a common lung disease causing restricted airflow and breathing problems), and high blood pressure.…

  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 before2025-05-20 · 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 the facility's only kitchen reviewed for food safety requirements and kitchen sanitation. 1. The facility failed to ensure the dietary manager, dietary aide and cook effectively wore a hair net to cover all hair. 2. The facility failed to ensure foods stored in the refrigerator and freezer were labeled and dated. 3. The facility failed to ensure foods stored in the pantry were sealed or in a sealed container. These failures could place residents at risk of foodborne illness and food contamination. Findings Include: During an observation on 05/18/2025 at 9:45am and on 05/19/2025 at 11:25, the DM, DA-G, DA-H and [NAME] had hair from under hair covering on the front, sides, and backs of their heads. During an observation on 05/18/2025 between 9:55am-10:25am, the following undated, unlabeled, and unsealed items were identified by Cook-F in the freezer, Refrigerator, and pantry: REFRIGERATOR: *1-bowel…

  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 before2025-05-20 · 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 observations, interviews, and record reviews, 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 2 of 13 residents (Resident #41 and Resident #196) and 6 of 9 staff (CNA A, CNA B, CNA O, CNA P, CNA Q, and LVN R) reviewed for infection control. 1.The facility failed to ensure CNA A and CNA B followed enhanced barrier precautions and performed hand hygiene when providing incontinent care to Resident #41 on 5/18/2025. 2.The facility failed to ensure CNA O performed hand hygiene between passing resident trays on 5/18/25. 3.The facility failed to ensure CNA P and CNA Q followed enhanced barrier precautions and performed hand hygiene when providing incontinent care to Resident #196 on 5/19/25. 4.The facility failed to ensure LVN R performed hand hygiene after removing non-sterile gloves and donning sterile…

  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 · E2025-05-20 · tag F0887 — pattern
  Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
  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 reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 5 of 5 residents who were reviewed for immunizations (Resident #24, Resident #25, Resident #44, Resident #49 and Resident #89). The facility failed to document, in Resident #24, Resident #25, Resident #44, Resident #49 and Resident #89 medical records, having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. This failure could place residents at risk of not being informed of complications 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-20 · 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 treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 8 residents (Resident #23) reviewed for resident rights. The facility failed to ensure the best friend did not speak degradingly to Resident #23 while attempting to assist with personal care on 5/19/25. These failures placed residents at risk of decreased feelings of self-worth and decreased quality of life. Findings include: Record review of facility face sheet dated 5/19/2025 indicated Resident #23 was a [AGE] year-old female admitted to the facility 8/9/24. Diagnosis included encephalopathy (a group of conditions that cause brain dysfunction), convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles), and profound intellectual disabilities (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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-20 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 6 residents (Resident #348) reviewed for medication storage. The facility did not ensure a medication named Digestive Enzymes was not stored at the bedside for Resident #348 on 05/18/2025. This failure could place all residents at risk of misuse of medication and decreased quality of life. Findings included: Record review of facility face sheet dated 05/18/2025 indicated Resident # 348 were an [AGE] year-old female admitted to facility on 05/10/2025 with diagnosis of Wedge Compression Fracture of T7-T8 Vertebra, Subsequent encounter with routine healing. Record Review of comprehensive care plan dated 05/10/2025 did not indicate Resident # 348 could keep medication at bed side or safely self-administer medications. The care plan reflects 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-11 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that residents were free of significant medication errors for 1 (Resident #1) of 3 residents reviewed for pharmacy services. The facility failed to ensure Resident #1 was free of significant medication errors when Resident #1 was administered another resident's medications, Glatiramer Acetate (medication to treat multiple sclerosis) by LVN A on 1/6/2025. The noncompliance was identified as PNC. The noncompliance began on 1/6/2025 and ended on 1/8/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician. Findings included: Record review of Resident #1's admission Record, dated 3/11/2025, reflected Resident #1 was a [AGE] year-old male. He was initially admitted on [DATE] and readmitted on [DATE]. He was noted to have diagnoses including symptoms and signs involving the musculoskeletal system, unspecified…

  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 · Past Non-Compliance
• Potential for harm · Fcited before2024-03-26 · 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 and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen. The facility failed to store foods in accordance with professional standards. The facility failed to date opened items placed in the refrigerator and correctly date dry storage items in the kitchen. These failures could place residents who ate the food from the kitchen at risk for food-borne illness. Findings include: During an observation and interview on 3/24/2024 at 9:15 AM the refrigerator contained a plastic container of a thickened white liquid and a large square plastic container with a red lid that had a gelatin type substance inside that was not dated. The dietary manager identified the white liquid as thickened milk. She said that both items were recently made. During an observation and interview on 3/24/2024 at 9:30 AM, the large plastic dry goods storage for sugar and breadcrumbs had a label with an open date of 01/10/2024 and good by date of 2/10/2024. The dietary manager said that 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-03-26 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for 2 out of 2 meals (the lunch meal on 03/25/24 and breakfast 03/26/24) reviewed for food and nutrition services. The facility failed to ensure residents (Resident # 8 and Resident #150) were served margarine listed on the menu during the lunch meal on 03/25/24 and breakfast 03/26/24. This failure could place residents at risk for unwanted weight loss and decrease satisfaction with meals. Findings included: Review of Resident #8's face sheet, dated 03/26/24, reflected he was an [AGE] year-old male who admitted to the facility on [DATE]. His diagnosis included muscle weakness, difficulty walking and lack of coordination. Review of Resident #8's admission MDS Assessment, dated 02/15/24, reflected he had a BIMS of 14 indicating he was cognitively intact and required set up service only for meals. Review of Resident #8's Physician Order summary for March 2024 indicated an order for a regular no salt on table…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-03-26 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 6 residents (Resident #41) reviewed for comprehensive care plans. The facility failed to care plan Resident #41's refusals to allow staff to perform tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe (trachea)) care. The facility failed to care plan Resident #41's desire to perform her own tracheostomy care. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings include: Record review of a facility face sheet dated 3/26/24 for Resident #41 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia (a serious condition…

  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

“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

$53,155 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $14,384 — penalty dated 2026-05-14
• $25,847 — penalty dated 2024-03-26
• $12,924 — penalty dated 2023-09-28
• Medicare payment denial — starting 2024-03-26 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 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.

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