Sienna Nursing and 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.

40.6% 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 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 65.2% 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 23 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 138 beds and averages 89.7 residents a day — about 65% occupied, or roughly 48 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 2.91 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.88 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 2.45 hrs/resident/day on weekends vs 3.10 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.54 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 92% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

Deficiencies are 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.

37 citations, most serious first. The 13 most serious are shown; the remaining 24 are one tap away and print in full.

• Immediate jeopardy · K2025-06-24 · 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 protect the resident's right to be free from abuse and neglect for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 18 residents reviewed for abuse and neglect. 1. The facility failed to prevent Resident #1 from abusing Resident #3 on Hall 400 (male secured locked unit) that led to an emergency room visit resulting in head laceration requiring 3 staples for Resident #3 on 05/25/2025. 2. The facility failed to ensure Hall 400 (male secured locked unit) had sufficient staffing to prevent Resident #1 from abusing Resident #4 that led to hospitalization of Resident #1 and a fall resulting in a skin tear to Resident #4's left elbow, while Resident #1 was supposed to be on 1:1 monitoring on 05/25/2025. 3. The facility failed ensure Hall 500 (female secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #5 resulting in a skin tear to her arm for Resident #5 on 06/04/2025. 4. 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-06-24 · 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 observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 18 residents reviewed for resident-to-resident altercations. 1. The facility failed to prevent supervision of Resident #1 from abusing Resident #3 on Hall 400 (male secured locked unit) that led to an emergency room visit resulting in head laceration requiring 3 staples for Resident #3 on 05/25/2025. 2. The facility failed to ensure Hall 400 (male secured locked unit) had sufficient supervising staff to prevent Resident #1 from abusing Resident #4 that led to hospitalization of Resident #1 and a fall resulting in a skin tear to Resident #4's left elbow, while Resident #1 was supposed to be on 1:1 monitoring on 05/25/2025. 3. The facility failed ensure Hall 500 (female secured unit) had sufficient supervising staff to prevent Resident #2 from abusing…

  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 · K2025-06-24 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 5 (Resident #1, Resident #2, Resident #4, Resident #5, and Resident #6) of 18 residents reviewed for sufficient staffing related resident-to-resident altercations and 1:1 monitoring. 1. The facility failed to ensure Hall 400 (male secured locked unit) had sufficient staffing to prevent Resident #1 from abusing Resident #4 that led to hospitalization of Resident #1 and a fall resulting in a skin tear to Resident #4's left elbow, while Resident #1 was supposed to be on 1:1 monitoring from a previous altercation on 05/25/2025. 2. The facility failed ensure Hall 500 (female secured unit) had sufficient staffing 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-04-23 · 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 interview, and observation, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis. The facility failed to ensure they employed a full time or interim DON from 02/25/2026 through present date of exit 04/23/2026.This failure could place all residents at risk of not receiving necessary care and services.Findings included:In an interview on 04/23/2026 at 10:24 AM with the Corporate Nurse, he stated he was the Interim DON. He stated he worked 2 days a week, 8-hour shifts, at this Nursing Facility as the DON. He stated he lived close by and was always readily available if needed. He stated he did not believe there was a potential risk for residents not having a full-time DON at the facility. He stated he monitored nurses and residents via online.In an interview on 04/23/2026 at 3:45 PM with the Administrator, he stated the Corporate Nurse was the current DON. He stated he was not aware how many days or hours the DON worked at the facility. He stated he did not believe there was potential risk to residents for not having a…

  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 · E2026-04-23 · 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

  Based on observation, interview, and record review the facility failed to ensure the residents right to personal privacy and confidentiality of his or her personal and medical records for 8 of 10 staff (LVN C, LVN M, MA N, MA O, RN H, LVN P, RN Q, RN G). The facility failed to ensure LVN C, LVN M, MA N, MA O, RN H, LVN P, RN Q, and RN G did not use their personal laptops to access residents' medical records and document care provided without any safeguards in place to ensure security of residents' confidential information. This deficient practice placed residents at risk for having their sensitive patient health information disclosed.Findings include: In an observation on 04/21/2026 at 2:57 PM LVN C was observed completing work on her personal computer during medication administration. On 04/23/2026 at 10:19 AM, LVN M was observed completing work on her personal computer. On 04/23/2026 at 10:35 AM, CMA N was observed completing work on her personal computer during medication administration. On 04/23/2026 at 10:43 AM, CMA O was observed completing work on her personal computer during…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-04-23 · 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 needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals for 3 of 3 residents (Resident #58, #68, #77) reviewed for respiratory care. - The facility failed on 04/21/2026 to ensure Resident #68's oxygen concentrator was turned on for 3 and a half hours as per vitals collected at 1:30 PM by LNV C.-The facility failed on 04/21/2026 to ensure Residents #58, #68, and #77 had an oxygen in use signage on the doorway entry. This failure placed residents at risk of not receiving respiratory care or the hazards of machine malfunction or accelerating the spread of fire associated with oxygen usage.Findings included: Resident #58 Record review of Resident #58's admission record dated 04/23/2026 revealed a [AGE] year-old male with an initial admission date 01/28/2026. Record review of Resident #58's comprehensive 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-04-23 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 4 items served on a sample tray (cold items) reviewed for food and nutrition services. -The facility failed on 04/22/2026 to provide a pudding dessert and tossed salad below 41 F. This failure places residents at risk of food-borne illnesses, decreased appetite, and overall meal dissatisfaction.Findings include: In an observation completed on 04/22/2026 at 12:31 PM, the facility provided a regular diet sample tray to the survey team to address meal service concerns. The sample tray arrived at the conference room at 12:43 PM, an 11-minute time elapse from the point it left the kitchen steam table. The sides that were intended to be served cold (below 41 F) were measured by the Dietary Manager and read at 53.2 F for a pudding dessert and 69.4 F for a tossed salad. In an interview on 04/22/2026 at 12:35 PM with the Dietary Supervisor I she stated temperatures…

  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 before2026-04-23 · 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 observations, interviews, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage. -The facility failed on 04/21/2026 to ensure a moldy tomato was not stored in the walk-in fridge.- The facility failed on 04/21/2026 to ensure different produce were not stored in the same bag (tomato with green onions).- The facility failed on 04/21/2026 to ensure a bag of green onions, bologna sandwiches, and hardboiled eggs in the walk-in fridge were labeled.- The facility failed on 04/21/2026 to ensure a box of chicken thighs was not leaking fluids, labeled, and was stored to maintain a temperature below 41 F. This failure had the potential to place residents at risk for foodborne illness.Findings included: During an observation and brief interview of the initial tour of the kitchen which began on 04/21/2026 at 8:35 AM with Dietary Supervisor I revealed at 8:41 AM, a tomato that had developed mold was stored in an unlabeled bag and shared the same space…

  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 · E2026-04-23 · tag F0850 — failed to provide social-work services — pattern
  Hire a qualified full-time social worker in a facility with more than 120 beds.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record review, the facility failed to employ a qualified social worker on a full-time basis with a facility of more than 120 beds for 1 of 1 Social Workers reviewed. -The facility failed to ensure social services were directed by a qualified individual on 4/23/26 in a facility with 138 total capacity. This failure placed residents at risk of receiving services from a staff member not qualified to identify as a social worker.Findings included: During record review of personnel files on 04/23/2026 at 8:35 AM, it was revealed the Social Services Coordinator did not complete her bachelor's degree in social work nor did she possess licensure from the Texas State Board of Social Worker Examiners. In an interview on 04/23/2026 at 8:36 AM with the Regional HR Coordinator stated the previous Social Worker passed away in May 2025 and the facility went 8 months without a Social Service department. She stated the facility did not have a policy on Social Services qualifications but followed the regulation for qualifications for a Social Worker. She stated the Social…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-04-23 · 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 safe operating condition for 1 of 1 walk-in fridge cooling system and 7 of 10 employees (LVN C, LVN M, MA N, MA O, RN H, LVN P, RN Q) not having access to facility issued laptops and desktops.-The facility failed to ensure water was not pooling under the walk-in fridge cooling system.-The facility failed to ensure laptops intended for nursing staff use were working. This failure placed residents at risk for delay in care and foodborne illnesses.Findings included: During an observation, brief interview, and record review of the initial tour of the kitchen on 04/21/2026 at 8:49 AM with Dietary Supervisor I, it was observed a small puddle of water was developing on the floor directly underneath the cooling system of the walk-in fridge. She stated she could not recall how long the walk-in fridge cooling system had been leaking for and added that she already submitted a work order to maintenance for it. A copy of the work order was requested from…

  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 · D2026-04-23 · 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's physician and their representative when there was a significant change in the resident's physical, mental or psychosocial status for 1 of 3 residents (Resident #68 reviewed for change in condition. -The facility failed to ensure LVN C reported Resident #68's oxygen being disconnected for unknown number of hours and oxygen saturation of 86% to the physician on 04/21/2026. This failure places residents at risk for experiencing a worsening condition and leaving the resident without appropriate treatment following a change in condition. Findings included: Resident #68 Record review of Resident #68's admission record dated 04/23/2026 revealed a [AGE] year-old Male with an initial admission date on 04/08/2026. Record review of Resident #68's physical and history dated 04/20/2026 revealed the resident was diagnosed with chronic obstructive pulmonary disease (a progressive, incurable lung disease), aphasia…

  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 · D2026-04-23 · tag F0585 — failed to handle grievances — isolated
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  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 evidence demonstrating the result of all grievances for a period no less than 3 years from the issuance of the grievance decision for 1 of 1 grievance binders reviewed. The facility failed to maintain evidence demonstrating the results of grievances prior to 2/13/2026. This failure could place residents at risk of not having their grievances properly resolved, tracked, and documented for future review.Findings include: An observation made on 04/21/2026 at approximately 1:30 PM revealed that the grievance binder provided did not have any documentation of grievances prior to 2/13/2026. In an interview on 04/23/2026 at 11:48 AM with the Social Services stated she began at the facility in February 2026 and there was no grievance documentation that she located upon taking office. She added that she did not discard anything. She stated she began taking grievances in February 2026 and utilizing a tracking binder. She stated prior to February 2026 she does not know how grievances were being tracked. She stated…

  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 · D2026-04-23 · 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 observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 3 residents (Resident #12) reviewed for ADL care. -The facility failed on 04/21/2026 to ensure Resident #12's fingernails were trimmed. This failure could place residents who required assistance with ADL's at risk for unmet needs.Findings included: Record review of Resident #12's admission sheet dated 04/23/2026 revealed a [AGE] year-old female with an original admission date on 06/18/2020 and a readmission date on 02/26/2021. Record review of Resident #12's comprehensive MDS dated [DATE] revealed under section C the resident had a BIMS score of 15 with the significance being cognitively intact. Under section GG the resident was coded for needing setup or clean-up assistance for personal hygiene. Record review of Resident #12's care plan dated 04/02/2026…

  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

“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

$241,722 in federal fines across 1 penalty.

• $241,722 — penalty dated 2025-06-24

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 CREATIVE SOLUTIONS IN HEALTHCARE — 149 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 19 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 87% 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 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.

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