Beacon Harbor 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.

58.0% 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 150 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 64.1% 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 64 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 1.26 therapist hours per resident per day in 2026Q1 — more than 98% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 190 beds and averages 154.0 residents a day — about 81% occupied, or roughly 36 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 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 3.00 hrs/resident/day on weekends vs 3.56 on weekdays — 16% thinner on weekends. RN hours go from 0.30 to 0.26 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%. 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.

27 citations, most serious first. The 13 most serious are shown; the remaining 14 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-08-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #139) resident of three residents reviewed for assisted transfer. The facility failed to ensure on 02/01/2024 PT K used the Hoyer lift ( mechanical/patient lift designed to assist caregivers move patients from one place to another) correctly, attach the Hoyer lift sling pad and condcuted with assistance of a second person as care planned, when he transferred Resident #139 from his wheelchair to the bed. On 02/01/2024 Resident #139 fell from the Hoyer lift sling pad while in use fracturing the right clavicle (right shoulder), right femoral neck (hip), right proximal tibia fracture (long bone in the right lower leg) and sustained an intraventricular hemorrhage (bleeding into the brain). The noncompliance was identified as PNC (past non-compliance). The 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 · Past Non-Compliance
• Immediate jeopardy · Jcited before2023-06-30 · 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 residents received adequate monitoring and supervision to prevent elopement for 1 of 1 (Resident #133) reviewed for accidents hazards/supervision. The facility failed to implement interventions to prevent elopement and failed to adequately supervise Resident #133 to prevent him from leaving the facility on 06/05/2023 without staff knowledge. Resident #133 was located 0.4 miles away from the facility. This failure could place residents requiring supervision at risk for serious injury and death. In Immediate Jeopardy (IJ) was identified to have existed from 06/05/2023 to 06/05/2023. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. The facility took the following actions to correct the non-compliance: moved Resident #133's room close to the nurse's station and placed a wanderguard bracelet on Resident #133. The facility…

  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
• Actual harm · G2023-09-20 · 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 interview and record the facility failed to ensure, based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents choices for 1 of 5 residents (Resident #7) reviewed for quality of care. The facility failed to ensure Resident #7 was accurately assessed, monitored, and treated for a change of condition when the resident was found to be in pain on 09/10/23 at approximately 10:30 PM. Resident #7 was not immediately sent to the hospital for emergency medical care. She was sent to the hospital on [DATE] after therapy staff notified the nurse of a leg deformity. At the hospital, Resident #7 was diagnosed with fractures of her left tibula and fibula (two bones in the lower leg, calf/shin area). This failure could place residents at the risk of not receiving appropriate medical interventions timely and effectively, which could result in severe injury and pain,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-03-24 · tag F0800 — pattern
  Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
  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 each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for three (Resident #1, #2, and #3) of ten residents reviewed for food preferences. The facility failed to provide hot palatable oatmeal at the breakfast meal for Residents #1, # 2, 3, and #4. This deficient practice could put residents at risk of weight loss, an increase of feelings of self-worth, and a decreased quality of life. Findings included: Record Review of Resident #1's quarterly MDS assessment, dated 03/10/2026, revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #1 had diagnosis which included: cerebral infarction (stroke), chronic respiratory failure (lungs are very weak), and atrial fibrillation (irregular fast heart rate). Resident #1 had severe cognitive impairment and required assistance of one…

  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 · D2025-12-11 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status in either life threatening conditions or clinical complications for 1 of 3 residents (Resident #1) reviewed for change in condition. The facility failed to ensure Resident #1's RP was notified when Resident #1 was found sitting up in bed with his midline IV (flexible catheter inserted into a vein in the arm) removed from his left arm on 12/03/25, which resulted in his arm having to be elevated and wrapped to lessen any swelling and bleeding. This failure could place residents at risk of their RP not being aware of conditions that may require them to make medical decisions. Findings include:Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-11-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for food safety.1. The facility failed to correctly discard food by the use by date for 1 storage bag of cheese.2. The facility failed to discard a dented can of soup.3. The facility failed to use or discard a tray with four containers of sliced/chopped vegetables by the discard dateThese failures could place residents at risk for food-borne illness and cross contamination.Findings included:Observation of the kitchen on 09/23/2025 at 9:40 a.m., revealed in the walk in refrigerator a storage bag containing sliced cheese was observed with a use by date of 09/21/2025. Observation of the walk refrigerator on 09/23/2025 at 9:45 a.m. revealed a tray with 4 containers, one with sliced onions, one with sliced pickles, one with lettuce, and another with sliced tomatoes. This tray had plastic wrap covering it with a use by date of 09/21/2025. Observation of the dry storage room on 09/23/2025 at 10:00…

  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 · E2025-11-20 · tag F0550 — failed to protect resident dignity and rights — pattern
  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 reviews, the facility failed to provide each resident with a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 5 residents (Resident #13) reviewed for resident rights.1. The facility failed to remove Resident #13 from contact isolation as ordered. Failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. findings included: Record review of Resident #13's face sheet, dated 09/25/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing inflammation and narrowing of the airways, making it difficult to breath), dysarthria following other cerebrovascular disease (slurred, slow, or unclear speech resulting from brain damage caused by stroke or other blood vessel problem in the brain), muscle weakness,…

  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 before2025-11-20 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (MA A) staff members and 3 of 4 residents (Residents #21, #91, and #42) reviewed for infection control procedures. MA A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #21, #91, and #42. These failures could place residents at risk for cross contamination and infections.Findings included: Record review of Resident #91's annual MDS assessment, dated 08/06/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #91 had diagnoses which included: Cardiovascular accident (stroke), and hypertension (high blood pressure). Resident #91 was moderately cognitively impaired and unable to make decisions. He required assistance from one staff…

  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 · Dcited before2024-12-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  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 the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for one (Resident#1) of four reviewed for environment. The facility failed to ensure Resident #1's sheets were clean and free of any stains. This failure could place residents at risk for a reduced quality of life and unsanitary and hazardous living conditions. Findings included: Record review of Resident #1's Face Sheet printed 12/04/2024, reflected a [AGE] year-old female who was admitted to the facility initially 06/02/2022 and readmitted on [DATE] and 12/11/2022 with diagnoses to include but not limited to Dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance (term used to describe a group of symptoms affecting memory, thinking and social abilities), high blood pressure and heart failure. 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 · D2024-12-04 · 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 the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive assessment and quarterly review assessments for one (Resident #1) of four residents were reviewed for comprehensive care plans. The facility failed to ensure the interdisciplinary team revised and reviewed Resident #1's care plan quarterly. This failure could affect residents by placing them at risk for not having their individual needs met. Findings included: Record review of Resident #1's Face Sheet printed 12/04/2024, reflected a [AGE] year-old female who was admitted to the facility initially 06/02/2022 and readmitted on [DATE] and 12/11/2022 with diagnoses to include but not limited to dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance ( term used to describe a group of symptoms affecting memory, thinking and social abilities), high blood pressure 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-12-04 · 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 maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #2) of 4 residents reviewed for accuracy of medical records. The facility failed to ensure the nursing notes accurately reflected Resident #2's condition. The nursing notes dated 08/17/2024 indicated the resident had old bruises to the bilateral upper arms, chest area and knees that were old however those bruises were new following the fall on 08/17/2024. These failures could place residents at risk for medication and /or treatment errors and omissions in care. Findings included: Review of Resident #2's electronic face sheet printed 12/04/2024 revealed a 84 year- old female admitted to the facility initially on 03/30/2023 and re admitted on [DATE] with diagnoses that included but not limited to dementia(term used to describe a group of symptoms affecting memory, thinking and social abilities),…

  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 · E2024-08-22 · tag F0583 — failed to protect personal privacy — pattern
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure personal privacy during incontinent care for 4 (Residents#78,#71,#38, and #3) of 15 residents reviewed for privacy. The facility failed to ensure Residents#78,#71,#38, and #3 were not put at risk of being exposed to view from the outside of the facility and to other windows of the facility during incontinent care or getting dressed. This failure could place other residents at risk for embarrassment and loss of self-esteem and dignity. Findings included: Review of the admission Record indicated Resident #78 was [AGE] years old female admitted on [DATE]. Review of the MDS assessment dated [DATE] indicated Resident #78 had diagnoses of cerebral vascular accident (stroke) and generalized muscle weakness and was dependent on staff for toileting, and hygiene. During an observation on 08/20/24 at 1:16 p.m., revealed Resident #78 was observed receiving incontinence care by LVN C. Resident #78's bed was located beside a window that had…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-08-22 · 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 provide a resident has a right to a safe, clean, comfortable and homelike environment for three of six resident halls (100, 200 hall and 300 hall) reviewed for physical environment. 1. The facility failed to ensure the intake vent at beginning of 100 hall was kept clean. 2. The facility failed to ensure resident rooms (102, 106 and 133) had a complete set of lateral blinds. 3. The facility failed to ensure resident room [ROOM NUMBER] was maintained with baseboards in place and the wall not exposed. 4. The facility failed to ensure hall 300 had safe handrails. These failures placed residents at risk for an unsanitary, unsafe, and uncomfortable environment. Findings included: 1. Observation of the 100 hall on 08/20/24 at 10:22 AM revealed the intake vent was covered in dust. 2. Observations of resident rooms 102, 106 and 133 08/20/24 at 11:00 AM revealed multiple missing vertical blinds. An interview on 08/20/24 at 11:05 AM with Resident #3…

  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

“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

$21,817 in federal fines across 2 penalties.

• $13,627 — penalty dated 2024-08-22
• $8,190 — penalty dated 2023-09-20

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 11 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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