Cambridge Health and Rehabilitation Center

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.

58.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 105 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 73.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 46 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 0.88 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 158 beds and averages 119.9 residents a day — about 76% occupied, or roughly 38 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 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 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 2.95 hrs/resident/day on weekends vs 3.36 on weekdays — 12% thinner on weekends. RN hours go from 0.48 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

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

• Immediate jeopardy · Kcited before2024-02-01 · 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 observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for 1 (CR #1) of 6 residents reviewed for pressure ulcers. -The facility failed to prevent the development of CR #1's Stage IV facility acquired sacrum pressure wound and left heel deep tissue injury resulting in debridement and hospitalization. Resident was diagnosed with sepsis due to MRSA, Sacral osteomyelitis and sacral pressure ulcer. -The facility failed to timely intervene when CR#1's Stage IV Pressure ulcer continued to get worse and did not send him to the local hospital and only suggested hospice. -The facility failed to ensure a wound care specialist physician was notified that CR#1's facility acquired Stage 4 pressure Ulcer was…

  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 · K2023-09-29 · tag F0678 — failed to provide CPR when needed — pattern
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  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 basic life support, including cardiopulmonary resuscitation (CPR) for 1 (CR#1) of 12 residents reviewed for advanced directives. 1. The facility failed to immediately initiate CPR on 8/31/23 at about 7:20 AM when CR#1 was found unresponsive. 2. The facility failed to immediately contact EMS when CR#1 was found unresponsive between 7:00 AM and 7:20 AM. EMS was called at about 7:32 AM. (12-32-minute delay). 3. The facility failed to ensure CPR was performed on a cardiac board once initiated by staff. A cardiac board is used in the administration of cardiopulmonary resuscitation (CPR) by creating a flat, rigid surface to use under the person in need of care. An Immediate Jeopardy (IJ) situation was identified on 09/09/23. The IJ template was provided to the facility on [DATE] at 6:25 PM. While the IJ was lowered on 09/15/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not an Immediate…

  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 · J2023-09-29 · 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 interviews and record reviews the facility failed to ensure that licensed nurses have 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 2 of 21 nurses (LVN A and LVN G) reviewed for competencies and skill sets for assessments. 1. The facility failed to ensure LVN A immediately and properly assessed CR#1 after the resident's change in condition was identified by CNA B as reported to be acting abnormally. 2. The facility failed to immediately and properly assess CR#1 after an additional change in condition was identified by CNA B as reported to appear pale and not look good. 3. The facility failed to assess and monitor CR#1 for approximately 10 hours after a change in condition was identified. 4. The facility failed to complete competency checks for LVN A and LVN G. 5. The facility failed to complete competency checks prior to the nurses assuming job duties An Immediate Jeopardy (IJ) situation…

  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 · Jcited before2023-08-30 · 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 the environment was free of accident hazards and failed to provide adequate supervision to prevent accidents for 1 resident (Resident #1) of four residents reviewed for accidents and hazards. -The side rail on Resident #1's bed was not properly fastened to the bed frame, causing it to rotate and expose a metal rod. Resident #1 was transferred from the wheelchair to the bed, his lower right leg was punctured with the exposed metal rod, resulting in Resident #1 receiving 10 staples to his right leg. -Staff transferred Resident #1 from the wheelchair to the bed using one-person transfer. Resident #1 required two persons for transfers. An Immediate Jeopardy (IJ) was identified on 08/29/2023 at 02:54 p.m. While the IJ was removed on 08/30/21 at 04:15 p.m., the facility remained out of compliance at a scope of isolated with actual harm, due to the need to evaluate the effectiveness of the corrective systems. This failure could place…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-02-26 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for one (Resident #1) of six residents reviewed for care plans.The facility failed to specify in the care plan whether Resident #1 would be a 1-person or 2-person assist for bed mobility. Resident #1 sustained a fall out of her bed on 1/6/26 when CNA A attempted to provide a 1-person assist during incontinent care. Resident #1 sustained a comminuted, mildly impacted, intra-articular fracture of the distal left femur and returned to the facility with a leg immobilizer.This failure could lead to residents not having their individual, medical, functional, and psychosocial needs identified and cause a physical or psychosocial decline in health.Findings included:Record…

  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
• Actual harm · Gcited before2026-02-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of six residents reviewed for accidents and hazards.The facility failed to prevent Resident #1 from having a witnessed fall on 1/6/26 while CNA A provided incontinent care. Resident #1 sustained a comminuted, mildly impacted, intra-articular fracture of the distal femur.These failures could place residents at risk for harm, pain, and injury.Findings included:Record review of Resident #1's face sheet dated 2/4/26 indicated she was a [AGE] year-old female with an initial admission date of 12/22/23 and readmitted to the facility on [DATE]. Resident #1's diagnoses were: cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), displaced comminuted fracture of shaft of left femur, lack of coordination, cognitive communication deficit, reduced mobility,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-01-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  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(Resident#1) of 5 residents reviewed for pressure ulcers. The facility failed to ensure that no new pressure wounds were acquired at the facility. Resident #1 acquired a Stage 3 sacral wound. The facility failed to implement new interventions when the sacral wound was not healing, increasing in size and requiring debridement for necrotic tissue. The facility failed to ensure offloading and timely incontinent care was provided for Resident#1's sacral wound . This failure place residents at risk for wounds, infection, and pain. Findings Included: Record review of Resident #1's face sheet revealed a [AGE] year-old male that was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of spinal stenosis (a condition in which the space inside the bones of the spine get too small), dysphagia(difficulty…

  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 · D2026-03-25 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  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 personal privacy for 2 (Resident #1 and Resident #2) of 7 residents review for personal privacy. CNA A failed to cover Resident #1 and Resident #2 body when she left the room on 03/25/26 to get assistance. This failure could place residents at risk of feeling uncomfortable or embarrassed. Findings included: Record review of Resident #1's face sheet dated 03/25/26 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included the following: hemiplegia (severe or total paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (when blood flow to the brain) affecting the left non-dominant side, contracture (permanent tightening of muscles, tendons, skin, or tissue resulting from injury, lack of movement, or nerve damage) of knee, and dysphagia (difficulty swallowing). Record review of Resident #1'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 · D2026-03-25 · 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 a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence for 1 (Resident #4) of 7 residents observed for incontinent care. Resident #4's brief was heavily soiled in urine along with clothing on 03/20/26. This failure placed residents at risk for unwanted skin breakdown. Findings included: Record review of Resident #4's face sheet dated 03/20/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 12/13/25. Resident diagnoses included anxiety, assistance with personal care, history of falling, osteoarthritis (joint disease that cause cartilage {support bones by allowing the bones to move smoothly over one another}on the bones to wear down, and dementia (progressive brain disorders causing a cognitive decline such as memory loss, confusion, and behavior changes). Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS score…

  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 before2026-03-25 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain, and infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 2 of 7 (Resident #3, Resident #4) reviewed for infection control. CNA A failed to change Resident #4's brief every 2 hours. Resident #4 brief was observed being heavily soiled in urine and resident clothing was soiled on 03/20/25. CNA B and CNA C failed to wear full PPE when providing incontinent care for Resident #3. CNA B used hand sanitizer to disinfect Resident #3's bedside table. CNA B took linen from another resident's room to Resident #3's room to provide incontinent care. CNA B and CNA C cleaned Resident #3 back and forward instead of front to back during incontinent care. These failures placed residents at risk for unwanted infections and decrease in quality of life. Findings included: Record review of…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-02-26 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  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 a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 4 of 6 resident rooms in the 100 hall (Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for environment. The facility failed to ensure Resident #2, Resident #3, Resident #4 and Resident #5's rooms were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.Findings included:Resident #2Record review of Resident #2's face sheet dated 2/26/26 indicated he was a [AGE] year-old male with an original admission date of 6/24/13 and readmitted to the facility on [DATE]. His diagnoses included: acute hematogenous osteomyelitis (an infection that occurs in the bone) of left ankle and foot, acquired absence of other right toe,…

  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 before2026-02-26 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  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 resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for one of six residents (Resident #1) reviewed for clinical records.The facility failed to ensure Resident #1's Medication Administration Record (MAR) reflected the administration of Tylenol (medication to treat pain) was accurately documented on 1/8/26.This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.Findings included:Record review of Resident #1's face sheet dated 2/4/26 indicated she was a [AGE] year-old female with diagnoses of cerebral infarction (ischemic stroke caused by a blockage in brain blood vessels), displaced comminuted fracture of shaft of left femur, lack of coordination, cognitive communication deficit, reduced mobility, need for…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-23 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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, interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident's assessment, care planning, and transition of care for 1 (Resident #1) of 5 residents reviewed for PASRR services.The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting .This failure could place residents who were PASRR positive at risk of not getting the PASRR services for a better quality of life and could lead to a decline in health.Record review of Resident #1's face sheet dated 12/23/25 revealed a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses[KS1] included- contracture( a permanent shortening or tightening of the muscles, tendons, ligaments or skin, making it hard to fully move the affected body part or joint unspecified joint, cerebral palsy ( a permanent condition from early brain damage that affects movement, balance and posture causing issues like…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-15 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, 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 one (Resident #21) of 23 residents reviewed for pharmacy services. The facility failed to ensure MA A administered the medication Sevelamer Carbonate (a Phosphate binding medication to control Phosphorus levels for hemodialysis patients) with a meal to Resident #21 as ordered by the resident's physician. This failure to provide medications as ordered could lead to residents not receiving the care they require to reach their highest physical, mental and emotional wellbeing. Findings included: Review of Resident #21's admission face sheet undated reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. His diagnoses included end stage renal disease, and type 2 diabetes mellitus with diabetic…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-15 · tag F0812 — failed to store, cook, and serve food safely — isolated
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened after usage. 2. The facility failed to ensure that dietary staff did not leave a disposable plastic cup to scoop the cornmeal out of the container. These failures could place residents at risk of cross-contamination and foodborne illness. Findings included: During an observation on 05/13/2025 at 08:12 AM, an initial tour of the kitchen was conducted with the dietary manager of a walk-in dry storage area in the kitchen. Observation revealed that half of a 5-gallon bag of uncooked enriched macaroni that was open and undated. Further observation revealed a plastic cup was also left in a large container of cornmeal. During an interview on 05/15/25 at 10:18 AM, [NAME] A said all items should have dates on the items when they receive it. She also said a plastic cup should never be left in 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-03 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation , interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident #1) reviewed for infection control. Unknown A and Unknown B failed to use proper PPE for Enhanced Barrier resident (Resident #1). The facility failed to ensure Unknown A and Unknown B wore appropriate PPE when entering Resident #1s' room on 03/13/2025 who was on Enhanced Barrier precautions while they performed direct care. These failures could place residents at risk for spread of infection. Findings included: Record review Resident #1's face sheet, dated 02/26/25, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Anoxic Brain Damage (Brain damage caused by complete lack of oxygen supply to the brain, leading to…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-10 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  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 care plans were reviewed and revised by the interdisciplinary team after each assessment for 1 of 5 (Resident #1) residents reviewed for care plan timeliness and accuracy in that: The facility failed to ensure Resident #1's care plan accurately addressed his facility acquired sacral wound and MASD (moisture associated skin damage) to his groin. This failure could affect residents by placing them at risk of not having accurate assessments, which could compromise their plan of care. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old male that was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of spinal stenosis (a condition in which the space inside the bones of the spine get too small), dysphagia(difficulty swallowing foods or liquids), Type 2 Diabetes (a long-term condition in which the body trouble controlling blood sugar), congestive heart failure (a chronic condition in which…

  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

“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

$68,342 in federal fines across 4 penalties.

• $18,821 — penalty dated 2025-01-10
• $16,448 — penalty dated 2024-02-01
• $13,397 — penalty dated 2023-08-30
• $19,676 — penalty dated 2023-08-30

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 THE ENSIGN GROUP — 342 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 17 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

7 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.

This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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