Brentwood Terrace Healthcare 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.

39.4% 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 64 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 41.0% 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 39 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 0.39 therapist hours per resident per day in 2025Q4 — more than 69% of the 13,714 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 42% 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 14% — 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 119 beds and averages 76.0 residents a day — about 64% occupied, or roughly 43 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 3.04 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.73 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 2.76 hrs/resident/day on weekends vs 3.29 on weekdays — 16% thinner on weekends. RN hours go from 0.63 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 93% 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 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.

39 citations, most serious first. The 18 most serious are shown; the remaining 21 are one tap away and print in full.

• Immediate jeopardy · Lcited before2024-03-02 · tag F0725 — failed to have enough nursing staff — widespread
  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 interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 9 of 24 residents (Residents #9, #4, #41, #36, #44, #57, #130, #180, and #179 and 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient nursing staff to ensure adequate supervision and to prevent accidents involving Resident #44, who was physically assaulted on [DATE], Resident #4, had an unwitnessed fall on [DATE], Resident #4 was left unsupervised in the bathroom on [DATE] and self-transferred from the toilet to the wheelchair, Resident 180, sustained an unwitnessed fall with injury on [DATE] and expired on [DATE], and Resident #130 suffered unwitnessed falls on [DATE] and [DATE] in his room while only one CNA was available on the secured unit. The facility failed to provide sufficient nursing staff to ensure Resident #44, Resident #41,…

  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
• Immediate jeopardy · L2024-03-02 · tag F0835 — failed to run the facility competently — widespread
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  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 be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for 1 of 1 facility reviewed for administration. The facility administration failed to ensure adequate staff were available and aware of job functions to provide for residents needs when the facility's Administrator position experienced 4 changes within 6 months. The facility failed to ensure the DON was aware that she was the abuse coordinator in absence of the Administrator, and she did not report, investigate or prevent further incidents of abuse per the facility's policy. The facility administration failed to ensure adequate nursing staff were available to provide for residents needs which resulted in Resident #44's physical assault by Resident #41, Resident #130's, Resident #4's, and Resident #180's unwitnessed falls. The facility administration failed to ensure pharmaceutical services were…

  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
• Immediate jeopardy · Kcited before2024-03-02 · 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 to ensure the right of the residents to be free from abuse and neglect 7 of 11 residents reviewed for abuse and neglect. (Resident #'s 44, 55, 41, 47, 52, 179 and 36) The facility failed to ensure Resident #44 was protected from Resident #41 after an alleged resident to resident assault resulting in Resident 44 being sent to a local emergency. Resident #44 was assessed with a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel) when she was left alone with her alleged assailant Resident #41. The facility failed to ensure Resident #55 was not left alone with Resident #41 after he allegedly assaulted Resident #44. The facility failed to ensure Resident #179 was not verbally and physically abused by CNA B. The facility failed to ensure Resident #179 was not suffering on-going neglect by CNA B of not performing incontinent care and not responding to his call light. The facility failed to ensure Resident #36 was 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-03-02 · 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 observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations for 8 of 11 residents (Resident #'s 44, 55, 41, 47, 52, 179, 57 and 36) reviewed for abuse and neglect. The facility failed to report and investigate when Resident #44 was found to have a large purple bruise to her inner thigh and a fractured hip. The facility failed to ensure Resident #44 was protected from Resident #41 after a resident to resident assault allegation resulting in Resident # 44 being sent to a local emergency room. Resident #44 was assessed with a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). when she was left alone with her alleged assailant Resident #41. The facility failed to ensure Resident #55 was protected by not leaving him alone 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-03-02 · 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 each resident received adequate supervision and assistive devices to prevent accidents for 4 of 11 residents (Resident #'s 4, 44, 130, and 180) reviewed for accidents. The facility failed to ensure Resident #44 was provided with adequate supervision when she was physically assaulted by Resident #41 on [DATE]. The facility failed to ensure Resident #4 who required 1 person assistance with toileting was provided adequate supervision to prevent an unwitnessed fall on [DATE] at 10:30 p.m. The facility failed to ensure Resident #4 was not left unsupervised on the toilet on [DATE] and was able to self-transfer between the toilet and the wheelchair. The facility failed to ensure Resident #130 was not provided adequate supervision to prevent an unwitnessed fall on [DATE] and [DATE]. The facility failed to prevent incidents and accidents when Resident #180 sustained an unwitnessed fall with injury (moderate sized frontal scalp soft tissue…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-03-02 · tag F0755 — failed to provide safe pharmacy services — pattern
  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 interview, observation, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 9 of 24 residents (Resident #9, Resident #36, Resident #41, Resident #44, Resident #45, Resident #57, Resident #71, Resident #127 and Resident #179) and 1 of 1 medication storage room reviewed for pharmacy services. 1. The facility failed to ensure Resident #45's hospital discharge orders were reconciled accurately to include his Lantus (long-acting insulin used to lower blood sugar) 10 units every hour of sleep, Humalog (short acting insulin used to lower blood sugar) per sliding scale before meals, Farxiga 10 mg (used to control high blood sugar) daily, and Augmentin 875 mg-125 mg (antibiotic) after his discharge on [DATE] which resulted in his hospitalization for metabolic encephalopathy (condition in which brain function is disturbed due…

  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
• Immediate jeopardy · Kcited before2024-03-02 · tag F0760 — failed to prevent significant medication errors — pattern
  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 observation, interview, and record review the facility failed to ensure residents were free of any significant medication errors for 9 of 24 residents (Resident #9, Resident #36, Resident #41, Resident #44, Resident #45, Resident #57, Resident #71, Resident #127 and Resident #179) residents reviewed for medication errors. 1. The facility failed to ensure Resident #45's hospital discharge orders were implemented to include his Lantus (long-acting insulin used to lower blood sugar) 10 units every hour of sleep, Humalog (short acting insulin used to lower blood sugar) per sliding scale before meals, Farxiga 10 mg (used to control high blood sugar) daily, and Augmentin 875 mg-125 mg (antibiotic) every 12 hours after his discharge on [DATE] which resulted in his hospitalization for metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body) and hyperglycemia (elevated blood sugar at 926) on 02/25/2024. 2. The facility failed to ensure 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-03-02 · tag F0610 — failed to investigate and act on abuse reports — isolated
  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 interview, and record review the facility failed to have evidence alleged violations were thoroughly investigated to prevent further abuse for 1 of 11 residents (Resident #44) reviewed for abuse. The facility failed to thoroughly investigate when Resident #44 was found to have a large bruise to her right inner thigh measuring 17 centimeters x approximately 11 centimeters that was painful on 6/21/2023. The facility failed to thoroughly investigate when Resident #44 was transferred to the local emergency room and found to have a new fracture and dislocation of the right trochanter (hip joint) on 6/21/2023. An IJ was identified on 3/01/2024. The IJ template was provided to the facility on 3/01/2024 at 11:05 a.m. While the IJ was removed on 3/01/2024, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not having allegations of abuse, neglect or exploitation…

  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 · Ecited before2026-07-29 · 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

  Based on interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient nursing staff on 07/04/2026, 07/05/2026, 07/08/2026, 07/11/2026, 07/12/2026, 07/14/2026, 07/16/2026, 07/19/2026, 07/25/2026, 07/26/2026, 07/27/2026. This failure placed residents at risk of inadequate supervision, an unsafe environment, and not receiving timely care. Findings included: During a confidential group interview at an undisclosed date and time, residents in the group stated that they waited up to 3 hours for their call light to be answered. Residents stated these prolonged wait times occurred most frequently on the night shift and weekends. Residents stated staff would tell them they were short staffed when explaining delays in responding to call lights or providing care. Residents stated they believed there were not enough staff members available 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-07-29 · 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 observations and interviews, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 residents (Residents #44 and #89) and one lunch meal reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and had an appetizing temperature on 07/28/2026. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.Findings included:During an observation and interview on 07/28/26 at 12:34 PM, the lunch tray was sampled by the Dietary Manager and 5 surveyors. The sample tray consisted of beef steak with a glaze on top, which was hot and tender; the broccoli was lukewarm, overcooked, and bland; and the baked potato was undercooked and lukewarm. The Dietary Manager said the steak with glaze was good and tender; the broccoli could have been warmer, less cooked, and more season added; and the baked potato was not cooked enough and could have been warmer. The Dietary Manager said this failure placed residents at risk of not…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-07-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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 were offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 1 of 3 residents (Resident #56) reviewed for nutrition. The facility failed to ensure Resident #56 received her physician ordered supplement (magic cup) on 07/28/26 for her lunch meal.This failure could place residents at risk for weight loss or protein deficitsFindings included:Record review of Resident #56's face sheet, dated 07/29/26, reflected Resident #56 was an [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental ability that interferes with daily life), stroke, malnutrition (a health condition caused by a deficiency, excess, or imbalance in a person's intake of energy and/or nutrients), and muscle weakness. Record review of Resident #56's quarterly MDS assessment, dated 05/18/26, reflected Resident #56 rarely made herself…

  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 · D2026-07-29 · tag F0810 — isolated
  Provide special eating equipment and utensils for residents who need them and appropriate assistance.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 of 6 residents reviewed (Resident #46) for special eating equipment and assistance when consuming meals. The facility failed to provide Resident #46's physician ordered sip cup on 07/27/2026 during his lunch meal.This failure could place residents at risk for dehydration, diminished independence, and self-esteem.Findings included: Record review of Resident #46's face sheet dated 07/27/2026 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnose which included major depressive disorder (a common, serious mood disorder defined by persistent sadness, loss of interest in activities, and low energy lasting at least 2 weeks), unspecified intellectual disabilities (delayed motor and language milestones and trouble 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 · D2026-07-29 · tag F0849 — isolated
  Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
  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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 4 (Resident #7) reviewed for hospice services. The facility failed to obtain Resident #7's Interdisciplinary Group Meetings since the start of care. These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings Included: Record review of face sheet dated 07/29/2026 revealed Resident #7 was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of Dementia (severe memory loss and cognitive functioning). Record review of order summary…

  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 · Dcited before2026-07-29 · 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 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 4 residents (Resident#4) reviewed for infection control. 1.The facility failed to ensure CNA F did not use dirty linen and performed hand hygiene while providing incontinent care for Resident #4 on 07/28/26. This failure could place residents at risk for cross-contamination and the spread of infection. Findings included: 1.Record review of Resident #4's face sheet, dated 07/29/26, indicated he was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses which included quadriplegia (a medical condition causing partial or total paralysis of all four limbs and the torso, usually resulting from damage to the cervical spinal cord in the neck), and muscle weakness. Record review of Resident #4's admission 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
• Potential for harm · D2026-07-21 · tag F0744 — failed to care for residents with dementia — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  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 with dementia received appropriate treatment and services to maintain their highest practicable well-being for 1 of 7 residents reviewed for dementia care. (Resident #1)The facility failed to ensure CNA A, NA B, and RN C provided appropriate dementia care and services while providing incontinent care for Resident #1 on 7/21/26.This failure could place residents with dementia at risk for increased behaviors and decreased quality of life.Findings included:Record review of Resident #1's face sheet dated 7/21/26 indicated she was [AGE] years old and admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had diagnoses including dementia (decline in cognitive abilities such as memory, reasoning, language, and behaviors that interfere with ADLs), anxiety disorder (mental health condition characterized by excessive, persistent, and uncontrollable fear or worry), schizoaffective disorder, bipolar type (mental…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-04 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
  Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
  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 the necessary care and services in the area of hygiene, grooming, and incontinent care for 1 of 16 residents (Resident #1) reviewed for activities of daily living. The facility failed to ensure Resident #1 was provided with incontinent care every two hours as recommended for Resident #1, which resulted in bed linens being saturated with urine. This failure could result in pressure injuries, infection, psychosocial harm, and a decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 03/04/2026 revealed a [AGE] year-old female admitted [DATE] and readmitted [DATE] with diagnoses which included cerebral infarction (occurs when an artery blockage cuts off blood flow and oxygen to the brain), chronic obstructive pulmonary disease (a lung disease that makes breathing difficult), dysphagia (difficulty swallowing), diabetes mellitus type 2 (a chronic metabolic disorder where the body fails to produce enough insulin…

  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 before2025-11-21 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Resident #1) reviewed for resident rights. The facility failed to ensure CNA A treated Resident #1 respectfully when he required assistance with his TV, and she failed to address him prior to exiting his room on 11/11/2025. This failure could place residents at risk of decreased self-worth, loss of dignity, and a diminished quality of life. Findings included:Record review of Resident #1's face sheet dated 11/12/2025 indicated he was a [AGE] year-old male initially admitted to the facility 12/31/2021 and re-admitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system), heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's…

  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 · Dcited before2025-11-21 · 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 interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident and determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 4 residents (Resident #2) reviewed for pharmacy services. The facility failed to ensure Resident #2's Qulipta (medication used to treat migraines) was administered as ordered on 10/31/2025, 11/01/2025, and 11/02/2025. This failure could place the residents at risk of not having medications available for use and medications errors. Findings included: Record review of Resident #2's face sheet dated 11/12/2025 indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body) and migraine. Record review of Resident #2's Quarterly…

  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

“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

$234,447 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $234,447 — penalty dated 2024-03-02
• Medicare payment denial — starting 2024-03-30 for 20 days

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

The source lists no ownership percentage for any party here — 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.

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.

What families pay in TX