Legacy At Town Creek

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.

39.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 127 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 54.9% 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 51 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 0.67 therapist hours per resident per day in 2026Q1 — more than 91% 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 199 beds and averages 77.2 residents a day — about 39% occupied, or roughly 122 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 3.37 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.27 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 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 3.06 hrs/resident/day on weekends vs 3.49 on weekdays — 12% thinner on weekends. RN hours go from 0.28 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% 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 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.

38 citations, most serious first. The 15 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · K2024-06-06 · 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 residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 7 of 10 residents (Residents #1, #4, #3, #9, #6, #7 and #10) reviewed for abuse and neglect. 1. The facility failed to protect Resident #1 from abuse from Resident #2, Resident #3, Resident #4, Resident #6, and Resident #10 between 5/8/23-1/11/24. on 1/11/24 Resident #6 slapped Resident #1 on his helmet. on 11/13/23 Resident #3 grabbed Resident #1's arm causing 2 skin tears. On 10/29/23 Resident #1 was in the lobby hollering and Resident #2 went over and flipped Resident #1 out of his wheelchair causing him to fall on the floor. On 10/29/23 Resident #3 grabbed Resident #1's right arm causing skin tears to right arm. On 9/29/23 Resident #1 sitting in recliner yelling and Resident #2 went over to Resident #1 and hit him in the mouth causing his lip to bust open. on 9/19/23 Resident #1 hit Resident #10 and Resident #10 hit Resident #1…

  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 before2024-06-06 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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 written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 7 of 10 residents (Resident #1, Resident #4, Resident #3, Resident #9, Resident #6, Resident #7 and Resident #10) reviewed for abuse policies. 1. The facility failed to implement the abuse policy by failing to protect Resident #1 from abuse from Resident #2, Resident #3, Resident #4, Resident #6, and Resident #10 between 5/8/23-1/11/24. 2. The facility failed to implement interventions after multiple incidents of resident-to-resident altercations. 3. The facility failed to implement the abuse policy by failing to protect Resident #4 from abuse from Resident #1, and Resident #3 between 7/25/23- 3/8/24. 4. The facility failed to implement the abuse policy by failing to protect Resident #3 from abuse from Resident #1, and Resident #8 between 6/23/23-5/1/24. 5. The facility failed to…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-06-06 · 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 observation, interview, and record review the facility failed to have evidence violations were thoroughly investigated to prevent further abuse for 7 of 10 residents (Resident #1, Resident #4, Resident #3, Resident #9, Resident #6, Resident #7, and Resident #10) reviewed for investigating abuse. The facility failed to ensure a thorough investigation of allegations of resident-to-resident abuse in that: 1. The facility failed to implement the abuse policy by failing to investigate the incidents involving Resident #1 receiving abuse from Resident #2, Resident #3, Resident #4, Resident #6, and Resident #10 between 5/8/23-1/11/24. 2. The facility failed to investigate multiple incidents of resident-to-resident altercations. 3. The facility failed to implement the abuse policy by failing to investigate Resident #4 recieving abuse from Resident #1, and Resident #3 between 7/25/23- 3/8/24. 4. The facility failed to implement the abuse policy by failing to investigate Resident #3 recieving abuse from 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
• Actual harm · Gcited before2025-10-08 · 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 observations, interviews, and records review the facility failed to ensure respiratory care was provided, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (Resident #1) reviewed for Respiratory Care. The facility failed to ensure appropriate respiratory care was provided to Resident #1 on 10/1/25 when the facility transported her to a doctor's appointment with an empty oxygen tank. This failure could place residents who require supplemental oxygen at risk of hospitalization and diminished quality of life.Findings included:1.Review of an admission Record for Resident #1 dated 10/8/2025 indicated she was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of acute respiratory failure, pleural effusion (fluid between the lung and chest wall), and congestive heart failure (heart can't pump blood well enough to meet the body's needs).Review of a quarterly MDS for Resident #1…

  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
• Actual harm · Gcited before2024-06-06 · 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 10 residents reviewed for accidents. (Resident #27). On [DATE] CNA A failed to ensure a safe transfer for Resident #27 by transferring with only 1 staff member when she required 2 staff members for transfers which led to Resident #27 suffering a 4 cm toe laceration requiring sutures. The noncompliance was identified as PNC (past non-compliance). The non-compliance began on [DATE] and ended [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents who required supervision at risk of injury or accidents and hospitalization. Findings included: Record review of a facility face sheet dated [DATE] indicated that Resident #27 was a [AGE] year-old female admitted to the facility on [DATE] and subsequently re-admitted on [DATE] with diagnoses including: dementia, sarcopenia (gradual loss of muscle mass, strength, 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
• Potential for harm · D2026-01-07 · 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 consult with the resident's physician when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for 1 of 4 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's physician immediately on 12/11/25 at 3:00 a.m. when he fell in the dining room resulting in facial/scalp contusions and a hematoma to his forehead. Resident #1 was on dual antiplatelet therapy of Clopidogrel and Aspirin which increased the risk of intracranial bleeding and the physician was not notified of the fall with head injury until 4:21 a.m., a delay of 81 minutes. This failure could place all residents at risk of delayed medical care, pain, and hospitalization. Findings included: Review of an admission Record dated 1/7/26 for Resident #1 indicated he was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses of end…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-08-06 · 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation.The facility failed to ensure the [NAME] wore a beard covering on 8/5/2025 when he prepared food.These failures could place residents at risk of foodborne illness and food contamination.Findings included:During an observation on 8/5/2025 at 10:30 AM, revealed the [NAME] was in the kitchen pureeing food for the lunch meal. He had a full beard that was not covered.During an interview on 8/5/2025 at 10:45 AM, the [NAME] said he had been employed at the facility for 10 years and no one ever told him he needed to wear a cover for his beard. He said he should have a beard net on because of his facial hair and if staff did not wear a covering, then hair could drop into the food.During an observation and interview on 8/5/2025 at 11:30 AM, the DM was in the kitchen with the Cook. She said the [NAME] should have on a beard cover 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-06 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure all drugs were stored properly, for 1 of 3 medication carts reviewed for medication storage. The facility failed to ensure Resident #101's insulin Lispro multi-dose vial with an expired date of 7/10/2025 was disposed of. This failure could place residents at risk of not receiving the therapeutic benefit of medications prescribed. Findings included: 1.Record review of Resident #101's face sheet, dated 8/5/25, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (a condition where the body does not use insulin effectively, leading to high blood sugar levels), dementia ( A group of symptoms that affects memory, thinking and interferes with daily life), and bipolar disorder (causes extreme changes in mood and behavior). Record review of Resident #101's significant change MDS assessment, dated 7/28/25, indicated she was able to make herself understood…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-06 · tag F0813 — isolated
  Have a policy regarding use and storage of foods brought to residents by family and other visitors.
  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 maintain and ensure safe and sanitary storage of residents' food items, per facility policy for 1 of 4 resident's (Resident #80) personal refrigerators reviewed for food safety.The facility failed to ensure the refrigerator for Resident #80 did not contain three containers of yogurt that were past their use by dates from 8/4/2025-8/6/2025.This failure could place residents at risk for food borne illnesses. Findings include:Record review of active physician orders for Resident #80 dated 8/6/2025 indicated she had diagnoses of Parkinson's (a progressive disorder that affects movement), dementia, major depressive disorder (persistent feelings of sadness and loss of interest that may affect daily lift), and osteoporosis (brittle bones). Record review of an admission Record dated 8/5/2025 for Resident #80 indicated she admitted to the facility on [DATE] and she was [AGE] years old.Record review of a Significant Change MDS assessment 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-06 · 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) and 1 of 6 staff (CNA D) reviewed for infection control. The facility failed to ensure CNA D did not store dirty linens on the floor on 8/5/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings include: Record review of an admission Record dated 8/6/2025 indicated Resident #5 readmitted to the facility on [DATE] and was [AGE] years old.Record review of active physician orders dated 8/6/2025 for Resident #5 indicated she had diagnoses of hemiplegia affecting right side (paralyzed on right side), Parkinsonism, and depression.Record review of an Annual MDS assessment dated [DATE] for Resident #5 indicated…

  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 · Fcited before2024-07-31 · 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 safety requirements and kitchen sanitation. 1. The facility failed to ensure [NAME] wore a hair net effectively to cover all his hair on 7/30/2024. 2. The facility failed to ensure DA wore a hair net effectively and did not have hair out on the front and side of her head not covered by her hair covering on 7/31/24. 3. The facility failed to ensure all foods stored in the refrigerators, freezers, and dry pantry were labeled, dated, and not kept past their expiration dates. 4. The facility failed to ensure proper hand washing between tasks. 5. The facility failed to ensure ovens were clean and free of debris. 6. The facility failed to ensure the ice machine was free from a black, slimy substance. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During an observation of the cooler/refrigerator on 7/29/2024 at…

  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 · Dcited before2024-07-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 1 facility reviewed for accident hazards. The facility failed to develop and implement a policy and procedure to properly handle the care of Hoyer lift slings including interventions to inspect the Hoyer sling for signs of damage before each use and not removing damaged slings from service. This deficient practice could result in falls and injuries if damaged lift sling broke during mechanical lift transfers. The findings were: 1. Record review of a facility face sheet dated 07/30/2024 indicated Resident #43 was a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses of muscle weakness, diabetes (high glucose level in the blood), and essential (primary) hypertension (high blood pressure). Record review of a comprehensive care plan revised 06/17/2024 indicated Resident #43 was a lift transfer for all transfers. Record review…

  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 before2024-07-31 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 24 residents (Resident #81, and Resident #68) and 2 of 5 medication rooms (Medication room [ROOM NUMBER] and #2) reviewed for medication administration. The facility failed to dispose of expired medications from Medication Rooms #1 and #2 on 7/29/2024 These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization. Findings included: 1. Record review of an admission Record for Resident #81 dated 7/30/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, anxiety disorder (disorder involves persistent and excessive worry that interferes with daily activities), depression (feeling of sadness or loss of interest),…

  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 before2024-07-31 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 of 5 medication storage rooms (Medication room [ROOM NUMBER]) and 1 of 24 residents (Resident #30) reviewed for medication administration. The facility did not ensure medications were not stored at the bedside for Resident #30 on 7/29/2024. The facility failed to ensure Medication room [ROOM NUMBER]'s refrigerator was free of contaminants on 7/29/2024 when it was observed leaking water inside and had a medicine cup of white capsules that water was dripping on. This failure could place all residents at an increased risk of receiving contaminated medications/supplements resulting in adverse health consequences. Findings included: 1.Record review of an admission record for Resident #30 dated 7/30/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of senile degeneration…

  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 before2024-07-31 · 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 observations, interviews, 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 6 residents (Resident #80) and 1 of 8 staff (CNA F) reviewed for infection control. CNA F did not sanitize or wash her hands between glove changes when providing incontinent care to Resident #80 on 7/30/2024. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: Record review of an admission Record for Resident #80 dated 7/31/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of myopathy (disease that makes the muscles weak), atrial fibrillation (irregular heartbeat), major depressive disorder (persistent sadness or loss of interest that interferes with daily life), 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.

  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

$294,608 in federal fines across 2 penalties.

• $10,358 — penalty dated 2025-10-08
• $284,250 — penalty dated 2024-06-06

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 SOUTHWEST LTC — 10 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 20 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

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