Shady Acres Health & Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 84 beds and averages 42.9 residents a day — about 51% occupied, or roughly 41 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 3.87 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.44 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 3.32 hrs/resident/day on weekends vs 4.09 on weekdays — 19% thinner on weekends. RN hours go from 0.27 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% 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.

26 citations, most serious first. The 17 most serious are shown; the remaining 9 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-12-11 · 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 sexual abuse for two of six residents (Residents #2 and #3) reviewed for abuse. 1. The facility failed to ensure Resident #2 was free from sexual abuse when Resident #1 came into Resident #2's room on 11/02/2025 and inappropriately touched her breast and genital area. 2. The facility failed to ensure Resident #3 was free from sexual abuse when Resident #3 reported to facility staff on 11/04/2025 on an unidentified date Resident #1 touched her breast without consent. The noncompliance was identified as a past non-compliance (PNC) Immediate Jeopardy. The Immediate Jeopardy (IJ) began on 11/02/2025 and ended on 11/05/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included:Resident #1 Record review of Resident #1's admission record, 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Kcited before2025-10-23 · 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 observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for 7 of 10 residents (Resident #1, #2, #3, #4, #5, #6, and #7) reviewed for abuse. 1. The facility failed to ensure Resident #1, and Resident #6 were free from sexual abuse when Resident #6 was observed in the secure unit TV room with her hand down Resident #1's pants and Resident #1 was holding Resident #6's hand and arm and would not allow it to be removed. Nursing staff had to manually remove Resident #6's hand from Resident #1's penis and Resident #1 became angry on 03/12/2025. 2. The facility failed to ensure Resident #1 did not touch Resident #2 inappropriately when CNA A witnessed Resident #1 was up behind Resident #2 in dining room/nook area and put his hands on her shoulders and waist and started rubbing his privates against her backside (dry-humping - both residents clothed) on 08/20/2025. 3. The facility failed to ensure Resident #4 was free from physical abuse…

  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 before2025-10-23 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  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 that all alleged violations involving abuse were reported immediately to the abuse coordinator for immediate intervention and all alleged violations involving abuse were reported no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 7 of 10 residents (Resident #1, #2, #3, #4, #5, #6, and #7) reviewed for abuse. 1. The facility failed to ensure LVN H reported a verbal and physical abuse allegation immediately to the Abuse Coordinator when Resident #3 threw coffee and threatened to kill Resident #7. Resident #7 reacted and hit Resident #3 on side of head with her fist on 05/14/2025. 2. The facility failed to ensure LVN K reported a verbal abuse allegation immediately to the Abuse Coordinator when…

  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 before2025-10-23 · 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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 7 of 10 residents (Resident's #1, #2, #3, #4, #5, #7, and #8) reviewed for care plans. 1. The facility failed to develop, revise and implement interventions in Resident #1's care plan on 03/12/2025, 07/01/2025 and 08/20/2025 to include interventions to prevent sexual abuse of other residents. 2. The facility failed to ensure Resident #3's care plan was updated to indicate Resident #3 had alleged abuse allegations on 04/19/2025, 05/14/2025, 05/18/2025, 05/27/2025 and 06/11/2025. 3. The facility failed to ensure Resident #8's comprehensive care plan was completed to maintain the resident's highest practicable physical well-being for skin integrity, meeting…

  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 · Jcited before2024-07-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 3 of 14 residents (Resident #s 1, 2 and 3) reviewed for smoking. 1. The facility failed to ensure Residents #2 and #3 were smoking safely in a designated smoking area. On 07/19/24, Resident #1, who utilized oxygen, and Residents #2 and #3 (assessed as smokers) were in a nonsmoking area. Resident #1's oxygen caught on fire, and she sustained multiple burns to her face, chest, and hands. 2. The facility failed to ensure Resident #2 and Resident #3 did not keep their smoking materials in their room. 3. The facility failed to ensure Residents #2 and #3 were re-assessed for smoking safety. On 07/24/24 at 12:26 p.m. an Immediate Jeopardy (IJ) situation was identified. While the IJ was removed on 07/26/24, the facility remained out of compliance at a scope of isolated with no actual harm with potential for more than minimal harm that is 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-07-26 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolated
  Have policies on smoking.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow Federal, State, and Local laws and regulations regarding smoking, smoking areas, and smoking safety for 3 of 3 residents (Resident #s 1, 2, and 3) reviewed for smoking safety. 1. The facility failed to ensure Residents #2 and #3 were smoking safely in a designated smoking area. On 07/19/24, Resident #1, who utilized oxygen, and Residents #2 and #3 (assessed as smokers) were in a nonsmoking area. Resident #1's oxygen caught on fire, and she sustained multiple burns to her face, chest, and hands. 2. The facility failed to ensure Residents #2 and Resident #3 were supervised while they were smoking. 3. The facility failed to ensure Resident #2 and Resident #3 did not keep their smoking materials in their room. 4. The facility failed to ensure Resident #2 and #3 were re-assessed for smoking safety. On 07/24/24 at 12:26 p.m. an Immediate Jeopardy (IJ) situation was identified. While the IJ was removed on 07/26/24, the facility remained…

  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
• Actual harm · Gcited before2024-12-20 · 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 provide adequate supervision and assistance devices to prevent accidents for 1 of 14 (Resident #1)residents reviewed for accidents/supervision. The facility failed to ensure Resident #1's fall matt was adjacent to her bed on 11/08/24. Resident #1 fell had an unwitnessed fall and sustained a 3 cm laceration above her right eye. This failure could place residents at risk of severe injuries. Findings included: Record review of Resident #1's face sheet dated 12/19/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included Alzheimer's (brain disorder that destroys memory and thinking skills), dementia (decline in mental abilities), restless leg syndrome (neurological disorder that causes unpleasant or uncomfortable sensations in legs and an irresistible urge to move them), and Parkinson's (brain disorder that causes movement problems). Record review of Resident #1's care plan dated 05/16/24 indicated she was at high risk for…

  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 · F2026-04-29 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record reviews, the facility failed to utilize the services of a RN for 8 consecutive hours 7 days a week and designate a RN as a DON on a full-time basis for 1 of 1 facility reviewed for nursing services. The facility failed to ensure an RN worked for 8 consecutive hours for 20 of 116 days reviewed in January, February, March and April 2026. The facility failed to designate an RN as a DON on a full-time basis for 30 of 87 days reviewed in February, March and April 2026. This failure could place residents at risk of not having their nursing and medical needs met, and other direct care staff not receiving sufficient oversight. Findings included: During an record review and interview on 04/29/26 at 09:30 a.m. with the facility HR Director and record review of the facility's RN staff payroll hours for the period of 01/01/26 - 04/29/26 indicated no RN Services on the following dates: 01/03/26, 01/04/26, 01/17/26, 01/18/26, 01/22/26, 01/31/26, 02/01/26, 02/21/26, 02/22/26, 02/23/26, 03/01/26, 03/05/26, 03/10/26, 03/15/26, 03/19/26, 03/28/26, 03/29/26, 04/24/26,…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-04-29 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's 1 of 1 kitchen reviewed for food safety requirements. The facility failed to ensure there was no fly tape with bugs on it approximately 12 inches away from refrigerator B.The facility failed to ensure floors did not have a sticky substance.The facility failed to ensure there were no fuzzy green spots on refrigerator A's wire rack.The facility failed to ensure the ice machine was free of lime build up.The Dietary Supervisor and Dietary Aide/ [NAME] C did not have bread restraints on their beards. These failures could place residents at risk of foodborne illness, and food contamination. Findings included: During initial tour on 04/27/2026 at 8:51 a.m., the following were identified: The Dietary Supervisor and Dietary Aide/ [NAME] C did not have bread restraints on their beards. There was a long brown tape hanging from the ceiling approximately 12 inches from refrigerator B filled 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-29 · 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 residents were free of significant medication errors, for 1 of 14 residents reviewed for significant medication errors. (Residents #3)The facility failed to ensure staff held Resident #3's two blood pressure medications when the blood pressure was outside the prescribed parameters.This failure could place residents receiving medication to lower the blood pressure at risk for adverse consequences and decline in health.Findings included:Record review of Resident #3's face sheet reflected a [AGE] year-old male admitted on [DATE] with a diagnosis of hypertension (high blood pressure).Record review of Resident #3's quarterly MDS assessment, dated 03/11/26, indicated a BIMS score of 03 indicating Resident #3 was cognitively severely impacted. Hypertension was included as one of Resident #3's diagnoses.Record review of Resident #3's care plan dated 01/03/2026 indicated a diagnosis of hypertension. Interventions included Give anti-hypertensive…

  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 · D2026-04-29 · 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 observations, interviews, and record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles on 2 of 3 medication carts observed (Hall D and Hall C medication carts).The facility failed to ensure Hall D and Hall C medication cart drawers did not have loose pills in the bottom of the carts. These failures could place residents at risk of misappropriation of drugs, not receiving prescribed drugs or contaminated medication.Findings included:During an observation and interview on 04/28/2026 at 2:25 p.m., during review of the Hall D medication cart with the QA nurse, she said she was giving patient medication off this cart today. The cart review revealed the 2nd drawer contained 18 whole and 5 broken loose unidentified pills. The QA nurse said the medication cart should be cleaned and no loose pills should be in the drawers.During an observation and interview on 04/28/2026 at 2:39 p.m., during review of the Hall C medication cart with the QA nurse, she said she was giving patient medication off this…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-29 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #5) reviewed for infection control. The facility failed to ensure CNAs E and F wore PPE when providing ADL care to Resident #5 who was on enhanced barrier precaution. These failures could place residents at risk for cross contamination, spread of infection and sepsis, in violation of infection prevention and control requirements.Findings included:Record review of Resident #5's face sheet reflected a [AGE] year-old male admitted on [DATE] with a diagnosis of dysphagia (difficulty swallowing).Record review of Resident #5's quarterly MDS assessment, dated 03/12/26, indicated a BIMS score of 03 indicating Resident #3 was cognitively severely impacted. Feeding tube was included as one 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-12-11 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  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 report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 3 of the 4 incidents reviewed for reporting. 1. The Administrator or designated representative failed to report the results of an investigation within 5 days to the State Survey Agency for Resident #1's allegation of inappropriately touching Resident #2 reported on 11/3/2025 and Resident #1 allegation of inappropriately touching Resident #3 reported on 11/04/2025. 2. The Administrator or designated representative failed to report the results of an investigation within 5 days to the State Survey Agency for Resident #18's allegation of injury of unknown origin on 11/30/2025. This failure could affect residents if alleged violations are verified, and appropriate corrective actions are not taken.Findings include:Resident…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-12 · 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 for 3 of 6 residents observed for oxygen management. (Residents #1, #6, and #39) 1. The facility failed to keep the oxygen concentrator (machine that takes air from your surroundings and extract oxygen and filters the air into purified oxygen to breath) filter clean for Resident #1. 2. The facility failed to failed to keep the oxygen concentrator (machine that takes air from your surroundings and extract oxygen and filters the air into purified oxygen to breath) filter clean for Resident #6. 3. The facility failed on 02/11/2025 to apply clean filters to Resident #39's concentrator and the facility failed to clean the area manufactured to hold the filters in place. These failures could place residents at risk of a significant reduction in the quality of oxygen being delivered, inadequate oxygen support, and decline…

  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 · E2025-02-12 · tag F0908 — failed to keep essential equipment working — pattern
  Keep all essential equipment working safely.
  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 maintain all mechanical, electrical, and patient care equipment in a safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove in the kitchen was in a safe operating condition when on 02/10/2025 one of six burners did not light when turned on. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner. Findings included: During an observation and interview on 02/10/25 at 8:30 a.m., the DM turned on the gas stove burners with 1 of 6 burners not lighting. The left front burner did not light but no gas was smelled. He said it lit up until now and no staff had informed him the stove was not working. The DM said he thought a pot may have over splashed yesterday evening and blew out the pilot light. The DM said he was responsible for ensuring all equipment in the kitchen worked properly. He said the staff were all educated to inform him or the Maintenance Director if any equipment was not working. He said…

  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 · D2025-02-12 · 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 observation, interview and record review the facility failed to ensure accurate assessments were completed for 1 of 14 residents (Resident #5) reviewed for accuracy of assessments. The facility failed to ensure Resident #5's quarterly MDS assessment dated [DATE] was not inaccurately coded for injection and insulin use when Resident #5 had no diagnosis or order for insulin injections. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: Record review of Resident #5's face sheet dated 02/12/2025 indicated she was an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting left non-dominant side (left-side paralysis and weakness from a brain bleed), hypertension (high-blood pressure, and anxiety. There was no mention of diabetes or that Resident #5 was diabetic. 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 · Dcited before2025-02-12 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #6) of 14 residents reviewed for Infection Control. The facility failed to ensure Resident #6 pleural (tissue that lines the chest cavity and covers the lungs) drain bag (this is a flexible tube that drains fluid from the pleural space into in a drainage bag) and the drain port was not on the floor on 02/11/2025. This failure could place residents at risk of cross-contamination and the development of infections. Findings included: Record review of admission sheet dated 02/10/25 indicated Resident #6 admitted on [DATE] was [AGE] years old with lung cancer, congested heart failure (chronic condition in which the heart does not pump well), and high blood pressure. Record review of the quarterly MDS…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$144,761 in federal fines across 4 penalties.

• $17,345 — penalty dated 2025-12-11
• $26,826 — penalty dated 2025-10-23
• $17,692 — penalty dated 2024-12-20
• $82,898 — penalty dated 2024-07-26

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.

Who owns this facility

CMS files one row per role, so the 6 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

About 76% 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. 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