Rosenberg Health & 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.

Met the expected recovery: 30.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 20 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 124 beds and averages 92.8 residents a day — about 75% occupied, or roughly 31 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 2.99 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.66 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 2.59 hrs/resident/day on weekends vs 3.15 on weekdays — 18% thinner on weekends. RN hours go from 0.56 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

29 citations, most serious first. The 18 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · Kcited before2025-11-20 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  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, a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, based on the comprehensive assessment for 1 of 5 residents (CR #1) reviewed for quality of care in that: CR #1 had a palm protector medical device on his contracted left hand for approximately 7 days, resulting in admission to an acute care hospital on [DATE] with left hand pain, cellulitis, and deep, open pressure wound that involved the thenar web space (the space between the index finger and thumb) that appeared chronic with a foul odor. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 11/11/25 and ended on 11/18/25. The facility corrected the noncompliance before the survey began. This deficient practice placed residents at risk of developing avoidable pressure injuries, severe pain, and decreased quality of life.…

  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 · Kcited before2025-03-25 · tag F0656 — failed to write and follow a full care plan — pattern
  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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment with services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement a comprehensive care plan including measurable objectives and timeframes to address Resident #1's medical, nursing, and mental and psychosocial needs related to his known history of signing himself out of the facility in a motorized wheelchair that did not belong to him, ambulating to nearby stores to drink alcohol until intoxicated/vomiting/lethargic and smoking marijuana in the surrounding community. As…

  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
• Immediate jeopardy · Kcited before2025-03-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure the resident received adequate supervision and assistance devices to prevent accidents as was possible for 1 (Resident #1) of 5 residents reviewed for accidents and supervision. -The facility failed to ensure a system was in place to adequately supervise Resident #1 when he left the faciity on [DATE] and did not return. The facility failed to notify law enforcement or conduct a thorough search for Resident #1. As of 03/21/25, the facility did not know Resident #1's whereabouts. An immediate Jeopardy (IJ) was identified on 03/21/25. The IJ Template was provided to the facility on [DATE] at 2:09 p.m. While the IJ was removed on 03/23/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). This failure placed residents at risk 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-03-25 · tag F0740 — failed to provide behavioral / mental-health care — pattern
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, encompassing the resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders for 1 of 12 residents (Resident #1) reviewed for behavioral services. The facility failed to ensure Resident #1 received adequate behavioral health care services to prevent and treat substance abuse disorder when Resident #1 frequently signed himself out of the facility to go to nearby stores and consume alcohol, resulting in intoxication, vomiting, and lethargy to the point of falling out of his wheelchair. Resident #1 was also known by staff to sign himself out and smoke marijuana in the community surrounding the facility, resulting…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2023-12-31 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 25 of 30 residents (Resident #204, #206, #92, #78, #9, #77, #73, #67, #39, #71, #74, #75, #20, #7, #44, #36, #50, #14, #30, #16, #82, #88, #70, #94, and #38) reviewed for infection control. The facility failed to ensure that Residents (#44, #36, #50, #14, #30, #16, #82, #88, #70, #94, and 38) who received negative COVID test results were not accommodated in a shared room alongside Residents(Resident #92, #78, #9, #77, #73, #39, #71, #74, #75, #20 and #7) who had tested positive for COVID 19 and were identified as droplet isolation precaution Residents. The facility failed to ensure transmission-based precaution protocols evidenced in the inadequate placement of notices and insufficient provision of Personal Protective Equipment (PPE) in the vicinity of residents' rooms or within their immediate proximity for the following 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-12-11 · 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 and timeframes to meet residents' physical, mental and psychosocial needs for 1 of 10 residents (CR#1) reviewed for care plans. The facility failed to implement CR #1's care plan, which included 1:1 monitoring for a history of diet noncompliance, to ensure he ate nothing by mouth. On 12/1/23, CR #1 was unsupervised during a meal and ate food that was not compliant with his diet, resulting in his death after a choking incident. An Immediate Jeopardy (IJ) situation was identified on 12/6/2023 at 2:55 p.m. While the IJ was removed on 12/8/2023 at 4:42pm, the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. This failure could place residents with no food by mouth (NPO) diet at risk of choking or death. Findings included: Record review…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-12-11 · 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 resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (CR #1) reviewed for accidents and supervision. The facility failed to provide adequate supervision to ensure CR#1 ate nothing by mouth when he had a Gastrostomy tube (G-tube) for enteral feedings due to dysphagia and history of aspiration/choking. On 12/1/23, CR #1 was unsupervised during a meal and ate food that was not compliant with his diet, resulting in his death after a choking incident. An Immediate Jeopardy (IJ) situation was identified on 12/6/2023 at 2:55 p.m. While the IJ was removed on 12/8/2023 at 4:42pm, the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. This failure could place residents at risk of injuries due to lack 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-07 · 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 resident's environment remained as free as possible of accident hazards and each resident received adequate supervision to prevent accident for 1 (CR #1) of 4 residents reviewed for adequate supervision. The facility failed to provide adequate supervision and training of the staff when they incorrectly used Hoyer lift while transferring CR#1 from a shower chair to her bed on 05/02/2024. This failure placed residents living in the facility at risk of harm due to avoidable accidents by staff not properly using equipment when transferring residents from shower chair. Findings included: Record review of CR #1's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses include cerebral infarction with aphasia, contracture unspecified joint, cognitive communication deficit, Type 2 Diabetes Mellitus with Hyperglycemia. Review of CR #1's MDS (Minimum Data Set) dated January 24, 2024, section C…

  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 · E2026-06-10 · 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 with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 7 residents (Resident #2) reviewed for pressure ulcers. The facility failed to complete wound assessments for Resident #2's left heel wound that developed in the facility for approximately 5 weeks. This failure placed the resident at risk for infection, impaired healing, further skin breakdown, and delayed identification of changes in wound status.Findings included: Record review of Resident#2's facesheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Type 2 diabetes, heart failure, Chronic Obstructive Pulmonary Disease, and morbid obesity. Record review of Resident #2's admission MDS dated [DATE] revealed BIMS score of 11 out of 15 indicating moderate cognitive impairment. Further…

  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 · D2026-06-10 · 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, interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 3 residents (Resident #1) reviewed for PASARR services. The facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days following Resident #1's Interdisciplinary Team meeting. This failure placed residents at risk for inadequate care, and losing access to specialized mental health or intellectual disability services.Findings included: Record review of Resident #1's facesheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: quadriplegia (the partial or total paralysis of all four limbs), neuromuscular dysfunction of bladder (brain, spinal cord, or nerve damage disrupts the signals between your…

  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 before2026-01-29 · 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 ACRONYMS:BIMS: Brief Interview of Mental StatusRN: Registered NurseDON: Director of NursingADON: Assistant Director of NursingMDS: Minimum Data SetADM: AdministratorBased on interview and record review, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment to ensure that resident's care plan was reviewed and revised by the interdisciplinary team to address 1 of 4 residents (Resident # 1's) allegation.The facility failed to ensure that Resident # 1's care plan was revised to address her sexual allegation This failure could place 94 residents at risk of being sexually abused.Record review of Resident # 1's admission face sheet dated 01/08/2026, retrieved on 01/28/2026 at 10:17 a.m., revealed she was an [AGE] year-old female who was admitted into the facility on [DATE]. Her diagnoses included: Bipolar disorder (mental health condition characterized by severe mood swings ranging from extreme high to low. Mild cognitive impairment (decline in…

  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 · Ecited before2025-02-27 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 Kitchen. -Thirteen 8 oz glasses of juice were not labeled and not dated in the facility refrigerator. -Nine 4 oz glasses of apple sauce were not labeled and not dated in the facility kitchen. This deficient practice could place residents who received meals from the main kitchen at risk for food borne illness. Findings included: Observation in the facility kitchen on 2/25/25 at 06:30 am revealed thirteen 8 oz glasses of juice and nine 4 oz glasses of apple sauce were not labeled (attach a label to something) or dated. Interview with the Dietary Manager on 2/26/25 at 4:01 pm, she said she starts her workday by making sure everything is correctly labeled and dated . She said she make sure the date and use by date are on each food item. She said if the item used is not labeled or dated the residents can get sick or have an allergic reaction. Interview with the [NAME] on 2/27/25 at 1:39 pm, she…

  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 · E2025-02-27 · tag F0814 — failed to dispose of garbage properly — pattern
  Dispose of garbage and refuse properly.
  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 dispose of garbage and refuse properly for 2 of 2 garbage dumpsters (dumpsters #1 and #2) reviewed for disposal of garbage. The facility failed to ensure 2 of 2 dumpster lids were secured. This failure could place residents at risk of infection for exposure to germs and diseases carried by rodents from improperly disposed garbage. Finding included: Observation on 2/25/25 at 7:15 am revealed Dumpster #1 and Dumpster #2 had their lids completely open with the garbage exposed. The cook said they were not the only ones using the dumpsters in the facility. Interview with the Nutrition Director on 2/26/25 at 4:01 pm, she said she had worked at the facility for seven years. The Nutrition Director said the dietary staff were responsible for the dumpster lids remaining closed. She said if the dumpster lid was open the residents are at risk for potential rodents that could come into the building and make the residents sick. Interview with the [NAME] on 2/27/25 at 1:39 pm, she said she had worked at the facility 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-27 · 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, 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 each resident for 1 of 5 residents (Resident #27) reviewed for pharmacy services. The facility failed to acquire and administer Resident #27's scheduled dose of Clonazepam for several days. This failure could place residents at risk of decreased therapeutic efficiency and a poor quality of life. The Findings were: Record review of Resident #27's face sheet, dated 02/27/25, revealed [AGE] year-old male resident who was admitted to the facility on [DATE] with diagnoses including Respiratory failure, Cerebral infarction (blood flow to brain is interrupted causing the brain tissue to die), depression, and Schizophrenia (Mental disorder that affects a person's ability to think, feel, or behave clearly). Record review of Resident # 27's annual MDS dated [DATE],…

  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 · D2024-09-27 · tag F0585 — failed to handle grievances — isolated
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  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 a grievance policy to ensure the prompt resolution of all grievances for 1 of 3 (Resident#1) residents reviewed for grievances. -The facility failed to establish a grievance policy that includes the right to obtain a written decision regarding a resident's grievance. -The facility did not provide a written decision to Resident #1 who filed grievances. These failures could place residents at risk for feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness. Findings included: Observation on 09/27/2024 at 2:01p.m., of the posting near the Receptionist area titled Abuse, Neglect and Grievances revealed the posting included the Administrator's name, title, and phone number. Record Review of Resident #1's face sheet, dated 9/27/2024, revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included cerebral palsy (a congenital…

  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 before2024-08-21 · 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 interviews and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for accidents hazards and supervision, in that: The facility failed to ensure Resident #1's noodles were served at the appropriate temperature, which resulted in a burn to the palm of her hand. The failure could place residents at risk of experiencing accidents, injuries, and/or death. Findings Included : Resident #1 Record review of the face sheet for Resident #1 revealed a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting diagnoses was epilepsy (neurological condition that causes unprovoked, recurrent seizures), unsteadiness on feet, seizures, unspecified convulsions, and dementia (memory loss). Record review of Resident #1's MDS assessment completed 05/31/24 revealed a cognitive score 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-21 · tag F0806 — failed to honor food preferences — isolated
  Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
  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 that each resident receives, and the facility provides food that accommodates resident allergies, intolerances, and preferences for 1 (Resident #2) of 5 residents reviewed, in that: [NAME] A denied Resident #2, the 2 cheese flour tortillas requested on his breakfast meal ticket every morning. This failure could place residents at risk for decreased quality of life and weight loss. Findings included: Record review of Resident #2's face sheet revealed a sixty-year-old man who was admitted to the facility on [DATE]. His admitting diagnoses was Parkinson's Disease (disorder that affects the nervous system and the parts of the body controlled by the nerves), kidney failure, reduced mobility, and obesity. Record review of Resident #1's MDS assessment completed 07/03/24 revealed a cognitive score of a 15 (cognitively intact) out of 15. Cognitive functioning in relation to eating revealed that supervision and set up was required during meals. 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-08-21 · 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 observation, interview, 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 (DA A) kitchen staff reviewed for dietary services . During lunch, DA A failed to wear gloves and properly clean his hands during service while he touched his face mask, key chain, and rubbed his eyes. This failure could place residents at risk for injury and food borne illness during food preparation and services. Findings included : In an observation and interview on 08/21/24 at 12:13 p.m., DA A was tasked with taking the finished plates off the hot line and putting them on the trays inside of the food cart. DA A was the only kitchen staff observed without gloves. During service, DA A touched his face mask covering his mouth. When he spoke, DA A used his bare hand to pull the mask down and speak with other kitchen staff. He bent over and grabbed the bottom of his shirt and pulled it up to his eye, which exposed his bare back and boxers. He used the shirt to wipe his eyes then dropped 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

“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

$97,334 in federal fines across 4 penalties. 1 Medicare payment denial on record.

• $17,345 — penalty dated 2025-11-20
• $25,587 — penalty dated 2025-02-27
• $14,518 — penalty dated 2023-12-07
• $39,884 — penalty dated 2023-12-07
• Medicare payment denial — starting 2025-05-27 for 13 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to HAMILTON COUNTY HOSPITAL DISTRICT — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 83% 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 $158K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX