Golden Estates 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.

41.3% 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 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 93 beds and averages 63.6 residents a day — about 68% occupied, or roughly 29 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.95 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 2.62 hrs/resident/day on weekends vs 3.56 on weekdays — 27% thinner on weekends — a notable drop. RN hours go from 0.41 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 58% is well above 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.

32 citations, most serious first. The 16 most serious are shown; the remaining 16 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-05-30 · 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 that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Residents #1) reviewed for accidents hazards and supervision: The facility failed to put effective measures in place to prevent Resident #1 from eloping. Resident #1 was found outside the facility near the access road near the expressway on Saturday, 5/10/25. The facility did not have a plan in place for monitoring the front door to ensure resident supervision/monitoring was in place to prevent Resident #1's elopement. An IJ was identified on 5/28/25. The IJ template was provided to the facility on 5/28/25 at 5:04 p.m. While the IJ was removed on 5/30/25, the facility remained out of compliance at a scope of isolated and a severity level of not actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to evaluate the effectiveness of its corrective systems This…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-02-28 · 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, it was determined the facility failed to ensure residents had a safe, clean, comfortable and homelike environment, for 30 of 75 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) and 11 additional residents with rooms on the 200/100 hallways (all residents of 300 affected), 3 of 3 halls (halls 300, 200 and 100) and affected residents who utilized the facilities hallways, and main living area reviewed in that: 1. The facility failed to ensure Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29) had a warm and comfortable environment on 2/18/2025-2/27/2025 when the local weather temperatures were as low as 21 and the inside facility temperatures were as low as 51 degrees Fahrenheit (F). The facility temperatures affected all three hallways of the facility, 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-07-28 · 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 observation, interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 17 residents (Resident #63) reviewed for physician notification of changes. The facility failed to consult with Resident #63's physician and provide all necessary details to the DON when Resident #63 had a significant change in condition on [DATE], that included pain, vomiting, diarrhea, and low oxygenation and subsequently died. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:28 PM. While the IJ was removed on [DATE], 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 that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could affect residents by…

  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
• Immediate jeopardy · J2024-07-28 · tag F0678 — failed to provide CPR when needed — isolated
  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 observation, interview and record review LVN A failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders follow physician orders and the resident's advance directives for 1 of 17 residents (Resident #63) reviewed for Full Code status. The facility failed to ensure emergency protocol was followed and failed to ensure Resident #63, who had a Full Code order in place, was provided continuous and uninterrupted CPR, after the resident was found unresponsive with no pulse or respirations, according to professional standards of practice on [DATE] when LVN A stopped CPR once and continued after obtaining an AED, and Resident #63 subsequently died. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:28 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level…

  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 · J2024-07-28 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who were fed by enteral means, received the appropriate treatment and services to prevent complications of enteral (intake of food through a tube in the gastrointestinal tract) feeding for 1 of 7 residents (Resident #63) reviewed for enteral feedings. 1. The facility failed to ensure all the necessary components of an order for enteral feeding were included for Resident #63 when Resident #63 was admitted to the facility on [DATE]; the order did not include formula type, total volume, time of administration, or contraindications. 2. The facility failed to recognize and respond appropriately when Resident #63 had a significant change in condition on 4/28/2024, that included pain, decreased oxygenation, multiple emesis, and fecal incontinence and subsequently died. This deficient practice could place residents with enteral feeding at risk for vomiting, aspiration pneumonia, pain and diarrhea. The findings included: An Immediate Jeopardy…

  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 · K2023-06-04 · 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 the comprehensive assessment of a resident, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 12 out of 16 residents (Residents #2, #3, #7, #11, #12, #16, #21, #23, #34, #107, #257, and Resident #258) reviewed for diabetic care in that; 1. The facility failed to administer injectable insulin for Residents #2, #3, #7, #11, #12, #16, #21, #23, #34, #257, and Resident #258, sporadically from 04/14/2023 to 05/13/2023, due to an update in the electronic medication system. 2. The facility failed to identify and assess for harm, report to the PCP, report to the Residents and/or their Representatives all residents who did not receive their insulin due to the systemic update in the electronic medication administration record. 3. The facility failed to in-service all staff, to include, temporary agency staff, for the update to the electronic medication administration record. 4. The facility failed to implement blood sugar monitoring…

  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 · D2025-11-21 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a resident's responsible party was informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose alternative options is he or she preferred for 1 (Resident #6) of 7 residents reviewed for resident rights. The facility failed to notify Resident #6's responsible party on 09/16/2025, prior to Resident #6 being administered an anti-anxiety medication, Alprazolam.This failure could affect residents and/or responsible parties by placing them at risk for not getting consent for medications and unknown side effects.Findings included:Record review of Resident #6's undated face sheet revealed Resident #6 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included Dementia (a general term for impaired ability to remember, think or make decisions), Depression (a mood disorder that causes persistent feelings of sadness and loss of interest) and…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-21 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that the MDS assessment accurately reflected the resident's status for 1 of 7 (Resident #1) whose MDS assessments were reviewed in that:1. Resident #1 had a diagnosis of Schizophrenia that was not coded on the MDS assessment. 2. Resident #1 had orders for a lidocaine patch and antibiotic that was not coded on the MDS assessment. This deficient practice could place residents at risk for inadequate care and services to meet their needs based on inaccurate MDS assessments.Findings included:Record review of Resident #1's undated face sheet revealed Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disorganized thinking), Cerebral Palsy (a disorder that affects a person's ability to move and maintain balance and posture) and Dementia (a general term for impaired ability to remember, think, or make…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-21 · 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 interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 7 residents (Resident #6) reviewed for accuracy of medical records.Resident #6 had an order from hospice upon admission on [DATE] to notify Resident #6's responsible party prior to administration of Alprazolam .5mg prn. The instructions to notify the responsible party were not included in Resident #6's Alprazolam order. This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. Findings included:Record review of Resident #6's undated face sheet revealed Resident #6 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included Dementia (a general term for impaired ability to remember, think or make decisions), Depression (a mood disorder that causes persistent feelings of sadness…

  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 before2025-08-15 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles, 2 of 3 medication carts (station 1 and station 2) observed, in that: The medication aide cart for station 2 contained 4 loose medication pills. The medication aide cart for station 1 contained 1 loose medication pill. These deficient practices could place residents who receive medications at risk for not receiving the intended therapeutic effects of medications. The findings included: The findings were: Observation on 8/14/2025 at 11:32 a.m. of the medication aide cart for station 2 revealed there were 4 loose medication pills inside one of the drawers. During an interview with LVN F on 8/14/2025 at 11:34 a.m., LVN F confirmed there were 4 loose medication pills inside a drawer of the medication aide cart for station 2. Observation on 8/14/2025 at 11:42 a.m. of the medication aide cart for station 1 revealed there was 1 loose medication pill inside one of the drawers. During an interview with LVN G 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-15 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  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 provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 1 facility beauty shop, in that: The facility beauty shop contained potentially unsafe items and was unlocked. This deficient practice could result in residents, staff, and/or the public encountering potentially unsafe items. The findings were: Observation on 08/14/2025 at 1:35 pm revealed the facility beauty shop, located on the 100 hall, was unlocked and no staff were in the room. Further observation revealed the beauty shop contained a container of bleach wipes labeled hazardous, keep out of reach of children, four tubes of hair color labeled avoid contact with eyes and skin and keep out of reach of children, and a package of plastic razors. During an interview with the Regional Nurse on 08/14/2025 at 1:40 pm, the Regional Nurse confirmed the beauty shop contained potentially unsafe items and should have been locked to protect residents, staff, and the public from encountering such items. 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-15 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  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 assessment accurately reflected the resident's status for 1 of 8 residents (Resident #2) whose assessments were reviewed. he facility failed to accurately document Resident #2's dental status on the resident's admission assessment dated [DATE]. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings were:Record review of resident #2's face sheet dated 08/12/2025 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including hypertensive heart disease without heart failure, unspecified dementia without behavioral disturbance, major depressive disorder, and legal blindness. Record review of Resident #2's comprehensive care plan, revised 07/24/2025, revealed the resident was on a No Added Salt diet, Minced and Moist texture, thin liquid consistency, served in a divided plate. There was no focus area indicating the resident's dental status. 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
• Potential for harm · Dcited before2025-08-15 · 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 observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in 1 of 1 kitchen in accordance with professional standards for food service safety.The facility failed to ensure a container of shredded cheese and a case of breakfast sausage were properly sealed in the reach-in cooler.These failures could place residents at risk for foodborne illness.The findings were:Observation on 08/12/2025 at 10:18 AM in the reach-in cooler revealed an opaque hard plastic container filled halfway with shredded cheese. The container was covered with a plastic lid. One corner of the lid was not sealed onto the container, exposing the cheese to the ambient air in the cooler. Observation on 08/12/2025 at 10:18 AM in the reach-in cooler revealed a cardboard case of breakfast sausage. The case was open and the bag inside the case was open, exposing the sausage to the ambient air in the cooler. During an interview on 08/12/2025 at 10:20 AM, the DM stated both the containers of cheese and breakfast sausage were opened and should have been sealed, 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-30 · 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 consult with the resident's physician and representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 18 residents (Resident #1) reviewed for resident rights. The facility failed to notify Resident #1's physician and representative when the resident was missing on 5/10/25. This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. The findings included: Record review of Resident #1's face sheet dated 5/28/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 5/10/25 with diagnoses that included unspecified dementia unspecified severity (general term used to describe a decline in cognitive function that is severe enough to interfere with daily life and activities)-without…

  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 · D2025-05-30 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  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 develop and implement baseline care plans that included the instructions needed to provide effective and person-centered care within 48 hours of admission for 1 of 1 resident (Resident #1) reviewed for baseline care plans: The facility failed to complete Resident #1's baseline care plan within 48 hours. This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care. The findings included: Record review of Resident #1's face sheet dated 5/28/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 5/10/25 with diagnoses that included unspecified dementia unspecified severity (general term used to describe a decline in cognitive function that is severe enough to interfere with daily life and activities)-without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #1's MDS discharge assessment 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-30 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 2 nurse medication carts (Unit 1 medication cart)reviewed for storage of drugs and biologicals. The facility failed to ensure the Unit 1 medication cart was locked and secured when Medication Aide U left a medication cart unlocked and unsecured on 5/29/2025. This failure could place residents at risk of medication misuse or drug diversion. The findings included: Observation and interview on 5/29/25 at 12:56 p.m. revealed the Station 1 medication cart was left unlocked and unattended in front of the Station 1 nurse's station, facing out into the main pathway where 6 residents were observed sitting in wheelchairs in front of the medication cart. Further observation revealed LVN AA was sitting behind the Station 1 nurse's station. LVN AA stated the medication cart was assigned to Medication Aide U. The Administrator walked up to LVN AA and the State Surveyor and stated the medication cart in Station…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$161,844 in federal fines across 3 penalties.

• $16,575 — penalty dated 2025-05-30
• $113,523 — penalty dated 2025-02-28
• $31,746 — penalty dated 2024-07-28

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 PARAMOUNT HEALTHCARE — 8 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 23 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

4 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.

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX