The Colonnades at Reflection Bay

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.

62.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 153 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 48.6% 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 74 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 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% 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 180 beds and averages 142.6 residents a day — about 79% occupied, or roughly 37 beds typically open. It usually has some room. 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 3.11 hrs/resident/day on weekends vs 3.61 on weekdays — 14% thinner on weekends. RN hours go from 0.71 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

42 citations, most serious first. The 18 most serious are shown; the remaining 24 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-10-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #2) of 4 resident reviewed for accidents and hazards. The facility failed to ensure Resident #2 did not leave the facility without supervision and/or staff knowledge on 06/06/2025 when she was found trying to cross the street and on 06/21/2025 when Resident #2 was found across the street at an apartment complex. The noncompliance was identified as PNC (past noncompliance). The Immediate Jeopardy (IJ) began on 06/05/2025 and ended on 07/06/2025. This failure could place residents at risk of unsafe elopements, injuries, hospitalization and/or death. Findings included: Review of Resident #2's face sheet reflected a [AGE] year-old-female admitted on initially admitted on [DATE] and discharged on 07/06/2025 with diagnoses of end stage renal disease (final stage of chronic kidney disease when the kidneys have deteriorated and no longer…

  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 · Past Non-Compliance
• Immediate jeopardy · J2025-10-24 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  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, observations, and record reviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one of eight residents (Resident #4) reviewed for enteral nutrition. The facility failed to ensure Resident #4 was not laid in a flat position while her feeding tube was actively flowing by CNA E on [DATE].The facility failed to ensure LVN D provided timely nursing care/interventions in response to Resident #4's possible aspiration on [DATE].An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 10:39 AM. While the IJ was removed on [DATE] at 2:20 PM, the facility remained out of compliance at a scope of isolate and severity level of actual harm because all staff had not been trained on safe positioning for residents receiving enteral feeding, aspiration precautions and timely interventions.This failure could place residents 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-10-24 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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 reviews, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques and ensure that all licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one of eight (Resident #4) residents. The facility failed to ensure Resident #4 was not laid in a flat position while her feeding tube was actively flowing by CNA E on [DATE].The facility failed to ensure LVN D provided timely nursing care/interventions in response to Resident #4's possible aspiration on [DATE].An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 08:04 PM. While the IJ was removed on [DATE] at 2:20 PM, the facility remained out of compliance at a scope of isolate and severity level of actual harm because all staff had not been trained on safe positioning for residents…

  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 · K2025-06-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to provide care consistent with professional standards of practice promoting healing and prevent new pressure ulcers from developing for 1 (CR#1) of 7 residents reviewed for pressure ulcers. -The facility failed to ensure CR #1 received the care and services to prevent a stage 2 pressure wound on her sacral from deteriorating to a Stage 4 measuring 7 (L) x 13 (W) x 3 (D). CR#1 was sent to a local hospital after family intervention and was diagnosed with fever and Sepsis. -The facility failed to immediately begin treatment after CR #1 was admitted on [DATE], a referral made by primary Physician on 3/14/2025 and the first visit by the wound care doctor/NP was on 3/26/2025. -The facility failed to implement new interventions when the sacral wound was not healing and required debridement for necrotic tissue. -The facility failed to ensure re-positioning was performed for CR #1, Resident #2, and Resident #3and did not have documentation on…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-02-18 · 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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 10 residents (CR #1 and Resident #440) reviewed for pharmaceutical services 1. The facility failed to ensure accurate administering of all drugs and biological to meet the needs of Resident #440, who was administered morphine more frequently than prescribed by the physician on [DATE] and who was administered with the incorrect dosage on [DATE]. 2. The facility failed to acquire, dispense, and timely administer all medications to meet the needs of CR#1, who missed 4 doses of Posaconazole (antifungal) 100mg delayed release tablet between [DATE] and [DATE]. An Immediate Jeopardy was identified on [DATE] at 1:28 PM, and on [DATE] at 9:27 AM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-12-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure, based on the comprehensive assessment of the resident, 1 resident (Resident #6) of 5 residents reviewed for wound care received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan. -Resident #6 had a blackened area on her right great toe. -Facility staff did not assess the toe prior to surveyor intervention. -Facility staff did not report the toe issue to the physician prior to surveyor intervention. -Facility staff did not provide treatment to the toe prior to surveyor intervention. The deficient practice could place residents at risk for worsening of the wound and possible pain associated with the wound. Findings include: Record review revealed Resident #6 was an [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure, hemiplegia (loss of use of one side), cerebral infarction…

  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 · G2023-10-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse and neglect for 1 (Resident #1) of 5 residents reviewed for abuse and neglect. CNA A yelled at Resident #1, slapped her left arm three times, and forcefully grabbed her arm, which caused a skin tear on her left arm on [DATE]. The noncompliance was identified as past noncompliance (PNC). The noncomplilance began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of physical or emotional distress, and injury. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (a condition in which the blood vessels have persistently raised pressure), dementia with behavioral disturbance (impaired ability to remember, think or make decisions), Alzheimer's disease (a brain destroys memory 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Actual harm · G2023-10-06 · tag F0607 — failed to have anti-abuse policies — isolated
  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 implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 5 residents (Resident #1) reviewed for abuse and neglect. The facility failed to appropriately implement written abuse policy which resulted in CNA A hitting and forcefully grabbing Resident #1 left arm which resulted in a skin tear during care. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. This failure placed residents at risk of physical or emotional distress, and injury. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (a condition in which the blood vessels have persistently raised pressure), dementia with behavioral disturbance (impaired ability to remember, think or make…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · Ecited before2026-05-01 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 3 of 6 medication carts (halls 100, 300, 600) reviewed for labeling and expired medications. The facility failed to label a Lantus vial and a mupirocin ointment tube with resident specific information in the medication cart located on the 300 hall.The facility failed to label a Nuedexta bottle with resident specific information in the medication cart located on the 600 hall.The facility failed to label Tetrahydrozoline HCL 0.05% with resident specific information in the medication cart located on the 100 hall. These failures had the potential to result in medication administration errors.An observation of the medication cart for hall 300 on 4/30/2026 at 10:00 a.m. revealed 2 medications not labeled with resident specific information. A vial of Lantus 100 units/ml insulin was not labeled located in a Lantus box. A tube of mupirocin ointment usp 2% was not labeled. In an interview on 4/30/20206 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-01 · 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 interview and record review, the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 of 31 residents (Resident #96) reviewed for resident rights. The facility failed to ensure Resident #96's right to be treated with respect and dignity on 4/15/26 when LVN U asked CNA Y to witness medication administration. A staff member poured medications in her mouth and LVN U asked her to open her mouth to ensure she swallowed them. Resident #96 had the ability to take medications independently. The failure could place residents at risk of emotional distress, embarrassment, and loss of dignity. Findings included:Record review of Resident #96's admission Record generated on 4/30/26 revealed she was admitted to the facility on [DATE] with diagnoses of pleural effusion (an abnormal, excess accumulation of fluid in the space between the lungs and chest cavity), interstitial pulmonary disease (a broad term for over 200 chronic, often progressive, lung conditions causing…

  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 · D2026-05-01 · tag F0627 — isolated
  Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure a post-discharge plan of care was developed with the participation of the resident and ensure post-discharge medical and non-medical services were arranged for 1 of 4 residents (CR #1) reviewed for discharge process. The facility failed to review discharge instructions with CR #1 upon her discharge from the facility.The facility failed to provide CR #1 with a copy of the discharge summary at the time of discharge which caused delay in receiving her motorized wheelchair.The facility failed to provide CR #1 with a reconciled medication list upon discharge, resulting in CR #1 being discharged home without her medications, including prescribed pain medications. CR #1 did not receive her medications until the following morning after discharge. This failure placed residents at risk for unmanaged pain, interruption of essential medications, and decline in condition. Findings included:Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-01 · tag F0645 — isolated
  PASARR screening for Mental disorders or Intellectual Disabilities
  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 accurately submit a PASRR Level 1 Screening screening when a resident admitted with a diagnosis of Mental Illness, Intellectual Disability or Developmental Disability for (1 Resident #9) of 4 residents reviewed for PASRR screenings. The facility did not correctly identify Resident #9 as having mental illness in their PASRR Level 1 Screening. This failure could place residents with documented mental illness diagnoses at risk of not receiving needed care and services in the appropriate setting. Findings included:Review of Resident #9's face sheet, dated 5/1/26 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: ileus (a condition in which the bowel does not work correctly), hemiplegia (complete paralysis) and hemiparesis (weakness) following cerebral infarction (a type of ischemic stroke), epilepsy (a brain condition that causes recurring seizures), dementia (loss of memory, language, problem-solving and other…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  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 residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 10 residents (Residents #33 and #28) reviewed for incontinent care. -Resident #1's Foley catheter bag was observed more than half full and was not emptied as needed during observation on 04/29/2026 at 11:22 a.m.- Resident #2's Foley catheter bag was observed more than half full and was not emptied as needed during observation on 04/30/2026 at 5:00 p.m. This failure could place residents with indwelling Foley catheter at risk of infection, sepsis, hospitalization and death. Findings included: Record review of Resident # 33's face sheet dated 03/02/2026 revealed, she was a [AGE] year-old female admitted on [DATE] with the following diagnoses: Sepsis (Life-threatening medical emergency caused by the body's response to infection that can lead to tissue damage, organ failure, and potential death), acute…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-01 · 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 observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care was provided care consistent with professional standard of practice, the comprehensive person-centered care plan, and the residents goals and preferences for 1 of 31 resident (Resident #93) reviewed for respiratory care.The facility failed to ensure Resident #93, who had COPD and required oxygen via nasal cannula, had a functioning oxygen concentrator for approximately 5 hours. Resident #93 was found to have oxygen saturation level below her baseline and complaints of not getting enough air.This failure placed the resident at risk for hypoxia (critical condition where body tissues are deprived of sufficient oxygen), respiratory distress, and deterioration of health. Findings include:Record review of Resident #93 face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: chronic respiratory failure with hypoxia (long-term condition where 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-11-20 · tag F0761 — failed to label and store drugs safely — pattern
  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 observation, interviews and record reviews, the facility failed to ensure drugs and biologicals were secure and labeled for 7 (MC#1, MC#2, MC#3, MC#4, MC#5, MC#6, and MC#7) out of 14 medication carts.The facility failed to ensure medication carts were:1. Locked and secured when not in use.2. Drugs and biologicals were labeled. The failures could place residents at risk of drug diversion, use of expired medication and harm.Finding included:During an observation on [DATE] at 1:50 pm MC#1 was left unlocked, unsecure with drawers faced outward. The surveyor observed the key lock protruding outward with a red visible dot.During an interview on [DATE] at 2:10 pm, CMA A stated she was near the cart. CMA A stated the cart should have been locked when she stepped away. CMA A stated residents could get into the cart and take medications.During an observation on [DATE] between 5:30am to 6:10 am revealed:*MC#1 and MC#2 on the 1st floor were unlocked, and unsecure with drawers faced outward. Observed the key lock…

  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 before2025-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and observations the facility failed to ensure the residents environment remained as free of accident hazards as possible for 2 (Rm#1 and Rm#2) of 6 bathrooms reviewed.The facility failed to ensure that sharps containers were not past the full line in 2 resident bathrooms. This failure could place residents at risk of being stuck by needles and cause infection.Finding included:During an observation on 11/20/25 at 9:30 am revealed RM#1 and RM#2 bathrooms sharps containers were observed above the full line.During an observation and interview on 11/20/25 at 10:05 am, the ADON and surveyor did a walk-through of RM#1 and RM#2. The ADON stated housekeeping and nursing staff were responsible for emptying out the sharp containers.During an interview on 11/20/25 at 11:10 am, LVN G stated the sharps container should be emptied once it got to the full line. LVN G stated the charge nurses had the key for the containers and sharps were disposed of in the red hazard bags.During an interview on 11/20/25 at 11:30 am, RN F stated when sharps containers were at full line then it…

  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 before2025-11-20 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for 1 (MC#2) out of 14 medication carts. The facility failed to ensure the medication cart was free of expired insulin vial dated 09/07 on [DATE]. The failures could place residents at risk of poor insulin blood sugar control from expired insulin. Finding included:During an observation on [DATE] at 5:34 am on MC#2, the surveyor observed 1-Insulin LSP Inje 100/ml was dated 09/07.During an interview and observation on [DATE] at 5:35 am LVN C stated the insulins were supposed to be dated when opened. LVN C stated that he did not administer insulin during his shift and did not touch the insulin. During an interview on [DATE] at 6:25 am, LVN E stated depending on the type of insulin it could stay on the cart for 28 days after being opened. LVN E stated expired medication should be…

  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 · E2025-10-24 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure all alleged violations involving, abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegations involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in seriously bodily injury to the state survey agency for 1 of 4 residents (Resident #2) reviewed for abuse and neglect reporting. 1. The facility failed report to the SSA when Resident #2 eloped from the facility on 06/05/2025. 2. The facility failed report to the SSA when Resident #2 eloped on 06/21/2025 when she was found across the street at an apartment complex. This failure could place residents at risk of further abuse, physical harm, mental anguish, and/or unsafe elopements. Findings include: Review of Resident #2's face sheet reflected a [AGE] year-old-female admitted on initially…

  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

“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

$120,183 in federal fines across 6 penalties.

• $10,361 — penalty dated 2025-10-24
• $17,345 — penalty dated 2025-10-24
• $44,960 — penalty dated 2025-06-06
• $29,782 — penalty dated 2025-02-18
• $9,525 — penalty dated 2023-12-08
• $8,210 — penalty dated 2023-10-06

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 CANTEX CONTINUING CARE — 37 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 26 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

About 77% 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. This home reported $1 paid to related parties (affiliated landlords or management companies) in its most recent 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 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