Palomino Place

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.

54.9% 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 186 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 49.5% 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 93 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 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 87.8 residents a day — about 73% occupied, or roughly 32 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 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 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 3.19 hrs/resident/day on weekends vs 3.82 on weekdays — 17% thinner on weekends. RN hours go from 0.63 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as 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.

32 citations, most serious first. The 15 most serious are shown; the remaining 17 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-08-27 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of three residents reviewed for pharmacy services.The facility failed to ensure Resident #1, who was NPO, did not receive a medication by mouth.The failure could place residents at risk for aspiration, choking, and death. An IJ was identified on 08/26/25. The IJ template was provided to the facility on [DATE] at 4:49 PM. While the IJ was removed on 08/27/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimum harm because all staff had not been trained on the Plan of Removal.Findings included:Record review of Resident #1's quarterly MDS assessment dated [DATE], reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. She 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-06-27 · 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 are free of any significant medication errors for 1 of 1 resident (Resident #1) reviewed for medication administration. The facility failed ensure Resident #1, who was at increased risk for stroke due to having history of heart failure and persistent atrial fibrillation as per hospital discharge records dated 05/29/25, was administered her physician-ordered warfarin (Coumadin); which resulted in the resident being sent to emergency room after developing drooping of the left side of the face and slurred speech. An Immediate Jeopardy was identified on 06/26/25. The IJ template was provided to the facility on [DATE] at 03:46:PM. While the Immediate Jeopardy was removed on 06/27/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy , due to the facility's need to implement corrective systems. The failure…

  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
• Immediate jeopardy · J2024-02-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 6 residents reviewed for quality of care. 1. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent him from eloping from the facility on 01/22/2024. 2. The facility failed to ensure staff recognized Resident #1 eloped and recognize Resident #1 as a resident of the facility when Resident #1 was encountered outside the 500 Hall door. 3. RN A failed to follow their elopement response policy when the 500 Hall door alarm sounded. The facility concluded Resident #1 eloped through the facility's 500 Hall exit and staff did not conduct a thorough search of the facility and its grounds when the alarm sounded. A past non-compliance Immediate Jeopardy (IJ) situation was identified on 02/13/24 at 11:30 AM. The Immediate Jeopardy began on 01/22/2024 and ended 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.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2026-05-22 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse.The facility failed to ensure Resident #1 was protected from Resident #2 who entered her room and engaged in non-consensual sexual contact with her on 5/21/2026.The failure placed residents at experiencing fear, emotional distress, and unwanted sexual contact, placing residents at risk for abuse and psychological harm.Findings include: Review of Resident #1's Quarterly MDS Assessment, dated 04/15/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. She had a BIMS score of 10 which indicated moderate cognitive impairment. She had diagnoses that included: vascular dementia with mood disturbance (memory and thinking problems caused by a reduced blood flow or small strokes in the brain, along with emotional changes like irritability, sadness, mood swings, or agitation), depression (persistent sadness, low…

  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 · H2025-07-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  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 a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for pressure ulcers.CNA A and CNA B failed to reposition Resident #1 as required by her orders and care plan on 07/30/25.The facility failed to ensure that Resident #1 did not develop 2 stage III wounds while at the facility. This failure could place residents with pressure wounds at risk of the wound worsening, leading to increased pain, infection, delayed healing, serious complications including sepsis, reduced mobility, and a lower quality of life.Findings included:Record Review of Resident 1's quarterly MDS assessment, dated 06/26/25, revealed she was a [AGE] year-old female, admitted to the facility on [DATE]. Resident #1 was sometimes understood and sometimes was able to…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-12-11 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 5 (Resident #38, Resident #80, Resident #90, Resident# 57 and Resident #18 ) of 16 residents reviewed for quality of life The facility failed to ensure: Resident #38 had his nails cut and cleaned. Resident #80 had her fingernails cleaned and trimmed and chin hair shaved. Resident #18 has his fingernails trimmed. Resident #90 had her fingernails cleaned and trimmed. Resident #57 had her fingernails trimmed and her chin hair shaved. These failures could place residents at risk for not receiving necessary care and services and a decreased quality of life.Findings include: 1- Resident #38Record review of Resident #38's quarterly MDS assessment, dated 09/07/25, reflected a [AGE] year-old male with an admission date of 01/30/25. Resident #38 had a BIMS score of 14 which indicated he 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide safe and appropriate respiratory care for a resident when needed.
  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 a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for two of three residents (Resident #50, and Resident #26) reviewed for respiratory care. 1.The facility failed to ensure LVN K maintained sterile/aseptic technique during tracheostomy care (a surgical opening in the neck providing a direct airway through the trachea) for Resident #50 on 10/02/25. 2. The facility failed to ensure Resident #26's had a physician order prior to administering oxygen on 9/30/25. These failures could place residents at risk for respiratory infections and at risk of receiving an incorrect amount of oxygen. Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-12-11 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 7 of 15 residents (Resident #72, Resident #73, Resident #79, Resident #80, Resident # 78, Resident # 21 and Resident #39) reviewed for infection control. 1. The facility failed to ensure CNA F and RA D utilized Enhanced Barrier Precautions and performed hand hygiene before and after checking Resident #72 for incontinence on 10/01/25. 2. The facility failed to ensure CNA F changed her gloves and performed hand hygiene while providing incontinence care for Resident #73 and failed to ensure both CNA F and RA D used enhanced barrier precautions and failed to perform hand hygiene before leaving the resident's room on 10/01/25. 3. The facility failed to ensure CNA F and RA D performed hand hygiene and glove changes…

  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 · E2025-12-11 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  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 provide a safe, functional, sanitary and comfortable environment for 1 of 8 residents (Resident #64) in that:Resident # 64's refrigerator in her room had food that was moldy and spoiled half-filled cup of coffee on 9/30/2025. This failure could place resident at risk for a diminished quality of life and a diminished clean, homelike environmentThe findings include:Record review of Resident # 64 Quarterly MDS dated [DATE] reflected, Resident #64 was an [AGE] year-old female admitted to the facility on [DATE]. Resident #64 was on Hospice care. Resident #64 BIMS score was 0 which indicated she had severe cognitive impairment. Her pertinent diagnoses included Hypertension (high blood pressure), Diabetes Mellitus (an increased blood glucose levels), Hyperlipidemia (high blood lipid levels), and non-Alzheimer's dementia (cognitive decline that is not caused by Alzheimer's disease).In an observation on 09/30/2025 at 12:21 PM revealed Resident #64…

  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 · D2025-12-11 · 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, observation and record review, the facility failed to complete an assessment that accurately reflects a resident's status for 1 of 5 residents (Resident #26) reviewed for accuracy of assessments.The facility failed to accurately complete Resident #26's Quarterly MDS Assessment related to the need for oxygen therapy. The facility failed to accurately complete Resident #26's Quarterly MDS Assessment related to the discontinued use of anti-coagulant therapy. This failure could place the resident at risk of not having met her needs. Findings includedRecord review of Resident #26's admission record dated 10/1/25 reflected a [AGE] year-old female with an original admission date of 2/28/25 and readmission date of 7/21/25. Pertinent diagnoses included Dementia, End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), Metabolic Encephalopathy (a condition where the brain does not receive enough oxygen or nutrients, leading to changes in brain…

  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 · D2025-12-11 · 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 interviews and record review the facility failed to include in the care plan services that will be provided to the resident for 1 (Resident #40) of 10 residents reviewed for comprehensive care plans.The facility failed to ensure Resident #40 was care planned for ADLs. This failure could put Residents at risk of receiving unnecessary treatments, not receiving care or services and further decline of their physical health. Findings included: Record review of a face sheet dated 10/02/25 revealed Resident #40 was an [AGE] year old female admitted on [DATE] with diagnoses including cerebral infraction (interruption of blood flow to the brain), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), acute respiratory failure with hypoxia (the lungs fail to adequately exchange oxygen from the air into the bloodstream), dementia (a decline in cognitive function), and unspecified lack of coordination (impaired balance or coordination). Record review of…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-11 · tag F0659 — isolated
  Provide care by qualified persons according to each resident's written plan of care.
  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 have the comprehensive care plan reviewed and revised by qualified persons after each assessment for 1 (Resident #26) of 10 residents reviewed for comprehensive care plans.The facility failed to update Resident #26's care plan to reflect doctor's orders to discontinue anticoagulant therapy on 8/14/25. This failure could put Residents at risk of receiving unnecessary treatments, not receiving care or services and further decline of their physical health. Findings included: Record review of Resident #26's admission record dated 10/1/25 reflected a [AGE] year-old female with an original admission date of 2/28/25 and readmission date of 7/21/25. Pertinent diagnoses included Dementia, End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), Metabolic Encephalopathy (a condition where the brain does not receive enough oxygen or nutrients, leading to changes in brain function, and Paroxysmal Atrial…

  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 before2025-12-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  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, based on the comprehensive assessment of the resident, a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of three residents (Resident #73) reviewed for incontinence care. The facility failed to ensure CNA F and RA D provided appropriate perineal care for Resident #73 when they failed to clean the resident's perineal area, separate the labia and wash downward and clean the inner thighs and groin area on 10/01/25. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown.Record review of Resident #73's quarterly MDS assessment, dated 09/01/25, reflected a [AGE] year-old female with an admission date of 02/28/24. The facility staff evaluated her cognition as severely cognitively impaired. She was dependent for all ADLs and was frequently…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-11 · 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 drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and in compliance with the state laws and regulations, which included the appropriate accessory and cautionary instructions and the expiration date when applicable for the facility's one of two (Whirlaway med room) medication rooms reviewed for storage. The facility failed to ensure a vial of Tuberculin Purified protein derivative (substance used for skin test for tuberculosis), that was opened and used, was dated and stored in its original package in the medication room refrigerator. This failure could place residents at risk of diminished effectiveness and not receiving the therapeutic benefits of the medications.The findings include: An observation on 09/30/2025 at 9:30 a.m. of the medication room refrigerator on Whirlaway hall with the DON revealed an undated opened vial of Tuberculin Purified protein derivative stored in a bag labeled hep lock solution (a very diluted heparin…

  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 · D2025-12-11 · tag F0919 — failed to provide a working call system — isolated
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure residents toileting facilities were adequately equipped to allow residents to call for assistance for 2 Residents (Resident #57 and Resident #64 ) of 16 residents reviewed for residents' call systems. The facility failed on 09/30/2025 to ensure the call light system was accessible to a resident, lying on the floor in the shared residents' toilets located inside the residents' rooms when the call lights were missing the pull strings, for: Resident #57 and Resident #64 This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers from their restroom. Findings included:Observation on 09/30/25 at 12:12 PM revealed residents' toilet call light pull string was missing for Resident #57 and Resident #64 in their shared toilet. In an interview and observation on 10/01/2025 at 9:16 AM with CNA L stated that the cord for the bathroom call light was missing. She stated that she…

  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

“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

$165,086 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $10,516 — penalty dated 2025-08-27
• $145,743 — penalty dated 2025-06-27
• $8,827 — penalty dated 2024-02-13
• Medicare payment denial — starting 2025-07-31 for 14 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 CANTEX CONTINUING CARE — 37 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 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

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