Paradigm At First Colony

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.

42.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.44 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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 150 beds and averages 103.5 residents a day — about 69% occupied, or roughly 46 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.90 hrs/resident/day on weekends vs 3.55 on weekdays — 18% thinner on weekends. RN hours go from 0.52 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 67% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

Inspection deficiencies

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

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

41 citations, most serious first. The 18 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · K2024-11-27 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  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 residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices based on the comprehensive assessment of resident for 1 (CR#1) of 18 residents reviewed for anticoagulants. -The facility delayed sending CR #1 to a higher level of care on 11/21/2024 when CR #1 experienced an unwitnessed fall with a head injury (swelling to right cheek). CR #1 was receiving the medication Eliquis (blood thinner). -CR #1 was diagnosed with an Acute Subdural Hematoma with mass effect An Immediate Jeopardy (IJ) was identified on 11/23/2024 at 4:24PM. While the IJ was removed on 11/25/2024, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility need to evaluate the effectiveness of the corrected system. This failure has the potential 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
• Immediate jeopardy · Kcited before2024-11-27 · 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 interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accident for 1 (CR #1) of 18 residents reviewed for accidents in that: - The facility failed to provide CR#1, who was on an anticoagulant medication, adequate supervision and interventions to prevent falls on 11/13/24, 11/14/24, 11/17/24, and 11/21/24 causing head injury and hospitalization. -The falls were unwitnessed, CR #1 had dementia and did not remember to use their call light when they needed assistance. Cr #1 was admitted to the hospital with diagnosis of Acute Subdural Hematoma with mass effect left craniotomy evacuation. An IJ was identified on 11/25/2024. While the IJ was removed on 11/27/2024, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility need to evaluate the effectiveness of the corrected system. This 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-10-24 · tag F0694 — pattern
  Provide for the safe, appropriate administration of IV fluids 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 parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #37) residents reviewed for intravenous fluids. - The facility failed to ensure Resident #37 had physician orders and care plan in place for monitoring and dressing change of Resident #37's PICC line (Peripherally Inserted Central Catheter, a tube inserted through a vein in the arm which passes to the larger veins near the heart and used to deliver medications, liquid nutrition or other treatments) from when Resident #37 was readmitted from the hospital with a PICC line on 9/09/2024 to 10/2/2024 when the NP put in an order for the PICC line to be discontinued. -The facility failed to ensure Resident #37 's PICC line was removed after completion of IV antibiotics which ended on 09/19/24. -The facility…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-08-15 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's right to be free from neglect for 8 of residents (CR#1, CR#2, Residents #3, #4, #5, #6, #7 and CR#8) of 9 reviewed for neglect. The facility failed to oversee the implementation of resident care policies and failed to ensure residents received appropriate wound care and CPR and were free of accidents and injuries. The facility Administration failed to thoroughly and accurately investigate the incident of CR#8 being found unresponsive with a laceration, requiring emergency services, and passing away at the facility, therefore, not identifying and correcting the CPR failures. The facility failed to ensure the administration and nursing staff were educated on CPR. The facility failed to identify onset of CR #1's three large unstageable pressure ulcer and initiate intervention. The facility failed to follow physician orders and treat pressure wounds for CR #1, #2 and Residents #3, #4, #5, #6, #7, for multiple days. The facility failed…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2023-08-15 · tag F0656 — failed to write and follow a full care plan — pattern
  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 interview and record review the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment plan of care for 2 of 9 residents (CR#1 and CR#8) reviewed for comprehensive care plans in that The facility failed to implement CR #1's comprehensive person-centered Care Plan for pain to provide pressure reducing and positioning devices (air mattress) and CR#1 did develop 3 pressure sores on [DATE]. The facility failed to implement CR#1's comprehensive person-centered Care Plan for ADL self-care deficits as she required extensive assistance of 2 support persons for bed mobility, toileting/incontinent care and transfers. The facility failed to care plan for CR#8's behaviors such as playing with his bed remote and rearranging his furniture. An Immediate Jeopardy (IJ) 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-08-15 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) for 1 (CR#8) of 9 residents reviewed for advanced directives. - The facility failed to ensure that CR#8 received CPR in accordance with professional standards of practice on [DATE]. -The facility failed to immediately initiate CPR on [DATE] at 4:19 a.m. when CR#8 was found unresponsive. -The facility failed to immediately contact Emergency Services on [DATE] at 4:19 a.m. when CR#8 was found unresponsive. EMS was contacted on [DATE] at 4:34 a.m. (15-minute delay). An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 2:34 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been effectively trained on CPR, calling the code, and immediately contacting Emergency Medical Services and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-08-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility failed to ensure residents received treatment and care in accordance with professional standards of practice for Seven (7) residents (CR #1, CR#2, Residents #3, #4, #5, #6, and #7) of seven (7) residents reviewed for quality of care. 1. The facility failed to provide weekly skin assessment for CR #1 who was non- ambulatory and bed bound. 2. The facility failed to identify onset of CR #1's three large unstageable pressure ulcer and initiate intervention. 3. Facility failed to follow physician orders and treat pressure wound for CR #1, #2 and Residents #3, #4, #5, #6, #7, for multiple days. 4. The facility failed to provide education to their nurses regarding wound care and documentation, and nurses responsibility to do wound care when the treatment nurse was not in the facility. 5. Facility failed to obtain physician order before applying wound care treatment (Santyl and betadine) on CR #2 An Immediate Jeopardy (IJ) was identified on 07/28/2023. The IJ…

  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
• Immediate jeopardy · Jcited before2023-08-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (CR#1) of 9 residents reviewed for accidents, hazards, and supervision. -The facility failed to safely transfer CR #1 when the Wound Care Nurse used a Hoyer lift and left her in the air unattended for about 45 minutes until CR #1's family member alerted LVN A. -The facility failed to adequately supervise CR #1 who was cognitively impaired when the Wound Care Nurse positioned her on her side and left her unattended after wound care resulting in an unwitnessed fall. -The facility failed to thoroughly document 3-day neuro checks to monitor CR #1 after her fall. -The facility failed to adequately document and notify the physician of CR#1's fall. -The facility failed to complete an Incident Report and investigation on the fall. An Immediate Jeopardy (IJ) was identified on 07/28/23. The IJ template was provided to the facility on 7/28/23 at 5:25 p.m. While…

  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 before2026-06-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  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 interview and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 (CR #1) residents reviewed for respiratory care.The facility administered oxygen to CR #1 without an order from the physician from [DATE] through [DATE].This failure could have placed residents who received respiratory care at an increased risk of developing respiratory complications and receiving a decreased quality of care.Findings includedRecord review of CR #1's face sheet dated [DATE] revealed she was admitted to the facility on [DATE] from the hospital and expired on [DATE]. CR #1 had diagnoses which included presence of aortocoronary bypass graft (surgery that created a new path for blood to flow around a blocked or narrowed artery in the heart), atherosclerotic heart disease (plaque buildup inside the arteries that…

  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 · D2026-03-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  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 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 for 1 of 4 residents (Resident #1) reviewed for rights. -The facility failed to ensure CR #1 was not left in a soiled bed after his colostomy bag leaked on the evening of 1/8/26.-The facility failed to ensure CR #1 was not left in a soaked bed of urine and tube-feeding formula after his g-tube leaked on 1/28/26. This failure could place residents at risk for decreased quality of life, decreased self-esteem and diminished dignity.Findings included:Record review of CR #1's face sheet dated 3/17/26, revealed a [AGE] year-old male with an original admission date of 12/6/23 and readmitted to the facility on [DATE]. CR #1's diagnoses included: atherosclerotic heart disease of native coronary artery, dementia (loss of memory, language, problem-solving and other thinking…

  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 · D2025-12-01 · tag F0551 — isolated
  Give the resident's representative the ability to exercise the resident's 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 interview and record review the facility failed to ensure resident representatives had the right to exercise resident's rights to the extent provided by state law for 1 of 1 (Resident #1) residents reviewed for resident rights.The facility failed to ensure clinical records were provided to Resident #1's Power of Attorney (POA) as requested.This failure could place residents at risk of their needs not being met or disrupted continuity of care. Findings Included:Record review of Resident #1's clinical record revealed a [AGE] year-old female admitted on [DATE] with the following diagnosis Altered Mental Status, Unsteadiness on feet, Muscle Weakness, Lack of Coordination, Unspecified Macular Degeneration, Psychotic Disturbance Mood Disturbance and Anxiety. Record review of Residents #1's History and Physical dated 3/15/2025 revealed resident was Alert x3 and AMS was resolved. Record review of Residents #1's admission MDS dated revealed upon admission resident had a BIMS score of 11out of 15, indicating…

  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 · D2025-11-14 · 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 residents had the right to reside and received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and or safety of the resident or other residents for 2 of 12 residents (Resident #1 and #2) reviewed for resident rights. The facility failed to ensure Resident's #1's and Resident #2's call lights were within reach on 11/12/2025. This failure could place residents at risk of their needs not being met. Findings include: 1. Record review of Resident #1's quarterly MDS assessment, dated 08/25/25, reflected a [AGE] year-old female with an original admission date of 02/07/24. Her diagnoses included non-Alzheimer's dementia (confusion, memory impairments, difficulty with attention), cerebrovascular accident, transient ischemic attack, or stroke (interrupted blood flow to the brain or temporary blockage to the brain), spinal stenosis (narrowing of one 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-09-08 · tag F0610 — failed to investigate and act on abuse reports — pattern
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated, and that the results of the investigations were reported to the State Survey Agency within five working days of the incident for 6 of 8 residents (CR #1, CR#2, CR#3, CR#6, Resident #4, Resident#5 ) reviewed for Abuse, Neglect, and Exploitation.The facility failed to submit via State Survey Agency database, TULIP the five-day thoroughly investigated evidence that the allegations made on 12/26/2024, by CR #1 and CR#2, stating that CNA A provided rough care during activities of daily living (ADL) assistance. The facility failed to submit via State Survey Agency database, TULIP the five-day thoroughly investigated evidence that the family complaint made on 12/26/2024, regarding rough care provided by MA L during medication pass to CR#3.The facility failed to submit via State Survey Agency database, TULIP the five-day thoroughly investigated evidence that the family…

  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 · D2025-06-01 · 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 observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident, for 1 of 1 Resident (Resident #1) reviewed for medication administration. MA-A did not pull down on the lower eye lid prior to instilling medicated eye drops to Resident #1. MA-A placed the medication cap for the eye drops on an unclean surface, with the inside facing down then replaced the cap onto the bottle after administering the medication to Resident #1. These failures could affect residents who received medication and place them at risk of not receiving the appropriate amount of medication and could result in an adverse reaction, infection, or a decline in health. Findings included: Record review of Resident #1's face sheet dated 06/01/25 revealed an [AGE] year-old female admitted to the facility on [DATE] and initially admitted 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-10-24 · 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 observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened or prepared and discarded after 72-hours (3 days) per facility policy. 2. The facility failed to store food off the floor in the storage room. 3. The facility failed to self-report to the local Department of Health for drain water backup in the kitchen, with less than a one-inch air gap. These failures could place residents at risk of food borne illness and disease. Findings Include: Observation of the facility kitchen in the walk in refrigerator on 09/30/2024 at 8:15 AM revealed the following: 1. A plastic bag of boiled eggs not labeled. 2. A plastic bag of fresh salad not labeled. 3. A plastic bag of shredded cheese not labeled. 4. A plastic bag of sliced American cheese dated open 9/24. 5. A plastic container of green beans dated open 9/29 6. A plastic container of cooked pasta dated open…

  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 before2024-10-24 · tag F0656 — failed to write and follow a full care plan — pattern
  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, interview 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 that are identified in the comprehensive assessment describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 3 residents (Residents #88 and #43) reviewed for comprehensive care plans. 1. The facility failed to care plan Resident #88's behavior of removing her oxygen cannula off her face and not properly storing the cannula when not in use. 2. The facility failed to care plan Resident #43 for potential skin issues due to being always incontinent with bladder and frequently incontinent with bowel . This failure could lead to residents not having their individual, medical, functional, and psychosocial needs identified and cause a 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-10-24 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  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 pharmaceutical services (including procedures that assure the accurate acquiring, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 5 residents (Resident #83 and Resident #205) reviewed for pharmacy services with 5 errors out of 33 opportunities from 2 of 2 staff (MA A and RN A) and a medication error rate of 15%. 1. The facility failed to ensure MA A administered Pantoprazole granules (medicine used to reduce amount of acid in teh stomach) mixed with 10 cc apple juice or applesauce per physician orders and Ferrous Gluconate (medicine used to treat or prevent low blood levels of iron) per physician orders for Resident #83 2. RN A failed to administer the following medications correctly for Resident #205: - Megastrol 40mg/ml oral suspension (medicines used to treat loss of appetite, malnutrition, and severe weight loss in patients with acquired immunodeficiency syndrome (AIDS) by not following…

  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 · D2024-10-24 · 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 ensure the resident's right to respect and dignity for 3 (Resident #78, Resident #70, and Resident #73) of 8 residents reviewed for respect and dignity, in that: 1. CNA M and MA J laughed while redirecting Resident #73 away from Resident #78 and #70. 2. CNA M and MA J called Resident #73 crazy while redirecting him away from Resident #78 and #70. This deficient practice could lead to psychosocial harm due to feelings of low self-esteem and/or embarrassment. The findings were: Record review revealed of Resident #78's Facesheet dated 10/14/2024 revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Her medical diagnoses included but not limited to cognitive communication deficit, diabetes mellitus (body's inability to regulate blood sugar) due to underlying condition with diabetic neuropathy (blood flow damage), muscle weakness, encounter for orthopedic aftercare following surgical amputation, acquired absence 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 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

$64,559 in federal fines across 2 penalties.

• $19,838 — penalty dated 2024-11-27
• $44,721 — penalty dated 2024-10-24

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 PARADIGM HEALTHCARE — 17 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 14 rows in the source record cover these 13 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.

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

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