Willowbend Nursing And Rehabilitation Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

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

Met the expected recovery: 63.3% 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 60 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 0.97 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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 162 beds and averages 131.3 residents a day — about 81% occupied, or roughly 31 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 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.27 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 3.13 hrs/resident/day on weekends vs 3.67 on weekdays — 15% thinner on weekends. RN hours go from 0.23 to 0.35 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.

31 citations, most serious first. The 14 most serious are shown; the remaining 17 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-01-17 · 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 observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for one of five residents (Resident #1) reviewed for notification of changes. -The facility failed to notify the physician when LVN C observed and documented a new wound on Resident #1's left toe, when Resident #1 was a high risk for infection due to comorbidities. -The facility failed to notify Resident #1's RP when LVN C observed and documented a new wound on Resident #1's left toe, when Resident #1 was a high risk for infection due to comorbidities. The noncompliance was identified as PNC. The IJ began on 12/11/23 and ended on 12/18/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not having their physician notified concerning…

  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 · Past Non-Compliance
• Immediate jeopardy · J2024-01-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure appropriate treatment and care was provided in accordance with professional standards, comprehensive person-centered care plan and resident choices for 1 of 5 residents (Resident #1) reviewed for quality of care. -The facility failed to notify the physician and provide interventions to monitor and treat Resident #1 when LVN C observed and documented a new wound on his left toe. Resident #1 was high risk for infection due to comorbidities. The noncompliance was identified as PNC. The IJ began on 12/11/23 and ended on 12/18/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not having their physician notified concerning their medical needs which would cause a delay in treatment and a decline in health. Findings include: Record review of Resident #1's face sheet, dated 12/28/23, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2023-11-03 · 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 interview and record review, the facility failed to ensure residents had the right to be free from abuse for one (Resident #1) of three residents reviewed for post-surgical aftercare. The facility failed to ensure Resident #1 received the necessary level of assistance and that staff were aware of physician's orders and PT evaluations to prevent injury. Resident #1 required revision surgery to the right shoulder. The noncompliance was identified as PNC. The IJ began on 09/13/23 and ended on 09/15/23. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of not receiving care and/or treatment recommended by physician. Findings included: Record review of the Acute Care Hospital After Visit Summary dated 08/31/23 to 09/04/23 revealed the following lifting restrictions: okay to work on active assisted range of motion with passive stretch, no active internal rotation as of now. Record review of Resident # 1's admission MDS assessment dated [DATE] revealed…

  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 · Past Non-Compliance
• Immediate jeopardy · Jcited before2023-09-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 24 (Residents #95) residents reviewed for abuse. The facility failed to ensure to ensure CNA A was adequately trained to deescalate Resident #95's aggressive behaviors when CNA A and Resident #95 had a verbal altercation in which CNA A aggressively responded to Resident #95's verbal abuse by calling him a derogatory name and threatened she would spit in his face. An Immediate Jeopardy was identified on 09/13/23 at 5:18 PM. The IJ Template was provided to the facility on [DATE] at 5:20 PM. While the Immediate Jeopardy was removed on 09/15/23 at 12:39 PM, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of isolated due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure placed residents at risk for abuse, and physical or…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-01-22 · tag F0583 — failed to protect personal privacy — pattern
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during medical treatment for three (Resident #10, #29, and #36) of eight residents reviewed for resident rights. 1. The facility failed to ensure LVN C closed Resident #10's door while checking his blood sugar and administering his insulin on 01/21/2026.2. The facility failed to ensure LVN C closed Resident #36's door before lifting his shirt to turn off his life vest on 01/20/2026.3. The facility failed to ensure RN E pulled the privacy curtain while changing Resident #29's g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) dressing on 01/20/2026.These failures could place the residents at risk of not having their personal privacy maintained while treatment was provided that could result to the residents feeling uncomfortable during treatment.Findings included: 1. Record review of Resident #10's Face Sheet, dated…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-01-22 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 10 of 20 resident rooms (room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10) observed for cleanliness. The facility failed to ensure Resident Rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 01/20/26 at 10:57 AM of room [ROOM NUMBER], reflected the windowsill had dirt and dead gnats. The shower floor had a rust like substance near a shower wall, and black and white substances around the center of the shower floor. The bathroom floor had white substances under the sink and near the toilet. had grayish…

  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 · E2026-01-22 · 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 observations, interviews, and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 8 residents (Resident #28, # 87, #136, and #147) reviewed for ADL care provided to dependent residents. The facility failed to ensure Residents #28, #87, #136, and #147 received their scheduled showers for January 2026. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings included: Record review of Resident #28's Face Sheet, dated 01/21/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #28 had diagnoses of muscle weakness and need for assistance with personal care. Record review of Resident #28's Quarterly MDS Assessment, dated 12/26/25, reflected the resident had moderate cognitive impairment. The…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-01-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for five of eighteen residents (Residents #22, #27, #49, #105, and #122) and three of six direct staff (ADON A, MA G, and LVN H) reviewed for accident hazard.1. The facility failed to ensure Resident #22 did not have 2 cans of aerosol air freshener spray in his room on 01/20/2026. 2. The facility failed to ensure Resident #27 did not have a can of Lysol spray in his room on 01/20/2026. 3. The facility failed to ensure Resident #49 did not have a pump bottle of hand sanitizer, a can of Lysol spray, and sanitizing wipes in his room on 01/20/2026.4. The facility failed to ensure Resident #105 did not have a can of aerosol air freshener spray in his room on 01/20/2026.5. The facility failed to ensure Residents #122's bed was lowered to the lowest position possible while she was lying in the bed.6. The facility failed to ensure ADON A did not leave a container 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-01-22 · 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

  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 who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for five of sixteen residents (Residents #12, #87, #32, #91, and #102 ) reviewed for respiratory care.1. The facility failed to ensure Resident #12's BiPAP mask was stored in a bag when not in use on 01/20/2026.2. The facility failed to ensure Resident #87's breathing mask was stored in a bag when not in use on 01/20/2026. 3. The facility failed to ensure Resident #32's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly when not in use on 01/20/2026. 4. The facility failed to ensure Resident #91's breathing mask (a medical device used to deliver medication in the form of mist directly to the lungs) was stored properly when not in use on 01/20/2026.5. The facility failed to…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-01-22 · tag F0761 — failed to label and store drugs safely — pattern
  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, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under property temperature controls, and permitted only authorized personnel to have access to the keys for four of eighteen residents (Residents #35, #105, #102, and #150) reviewed for medication storage.1. The facility failed to ensure LVN H did not leave Resident #35's medication on top of the medication aide's cart unattended on 01/21/2026. 2. The facility failed to ensure a bottle of over-the-counter peroxide was not in Resident #105's room on 01/20/2026.3. The facility failed to ensure that a nasal spray was not inside Resident #102's room on 01/20/2026.4. The facility failed to ensure an antifungal and topical (delivering medications directly to the skin) roll-on analgesic were not inside Resident #150's room on 01/20/2026These failures could place the residents at risk of accidental overdose, misuse of medications, 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-01-22 · 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 for the facility's only kitchen, reviewed for food and nutrition services. Specifically, the facility failed to ensure that the dining area coffee station and ice machines were maintained in a clean and sanitary manner to prevent contamination of food and beverages. These failures could place residents at risk for cross contamination and air-borne illnesses. Findings include:Observations on January 20, 2026 at 9:04 A.M, while approaching the kitchen to conduct the assigned kitchen tour for survey, the surveyor walked through the dining area. Upon entry into the dining area, the surveyor immediately observed the coffee station to be visibly filthy. Spilled coffee was observed on the countertops, on the exterior surfaces of the coffee machine, and on the floor directly in front of the coffee station. The coffee residue was dry, indicating it had been present for an extended period of time and had not…

  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 · E2026-01-22 · 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 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 four of twelve residents (Residents #73, #29, #36, and #117) reviewed for infection control. 1. The facility failed to ensure CNA K performed hand hygiene while providing incontinent care for Resident #73 on 01/21/2026.2. The facility failed to ensure RN E wore a gown while changing Resident #29's g-tube dressing on 01/20/2026.3. The facility failed to ensure LVN C wore a gown while doing Resident #36's treatment, who had an indwelling catheter (flexible tube inserted into the bladder to remove the urine), on 01/20/2026.4. The facility failed to ensure CNA F wore a gown and pair of gloves while changing Resident #117's linens, who was undergoing dialysis (a medical treatment that removes waste products from the…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-22 · 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 observations, interviews, 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 promoted maintenance or enhancement of his or her quality of life for two (Resident #81 and Resident #93) of twenty-one residents reviewed for dignity.1. The facility failed to ensure RN E was not standing when assisting Resident #81 with his drinks on 01/20/2026.2. The facility failed to ensure RN E was not standing when assisting Resident #93 with her food on 01/20/2026.These failures could place the residents at risk of not having their right to a dignified existence maintained that could lead to embarrassment.Findings included: 1. Record review of Resident #81's Face Sheet, dated 01/21/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) affecting the left side, and speech…

  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 · D2026-01-22 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each 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 observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #102) of eighteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #102 room was in a position that was accessible to the resident on 01/20/2026.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #102's Face Sheet, dated 01/21/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with convulsions (sudden irregular movement of the body) and muscle weakness.Record review of Resident #102's Quarterly MDS Assessment, dated 12/02/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 10. The Quarterly MDS Assessment…

  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

“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

$70,415 in federal fines across 3 penalties.

• $16,801 — penalty dated 2024-01-17
• $7,446 — penalty dated 2023-11-03
• $46,168 — penalty dated 2023-09-15

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 THE ENSIGN GROUP — 342 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 17 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

7 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.

This home reported $1.6M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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