Lakeside Nursing And Rehabilitation Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

44.5% 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 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 70.0% 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 70 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 0.74 therapist hours per resident per day in 2026Q1 — more than 93% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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 118 beds and averages 112.3 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. 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 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 2.69 hrs/resident/day on weekends vs 3.59 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.49 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

23 citations, most serious first. The 13 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · K2024-02-16 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident's right to be free from abuse for 3 of 5 residents (Resident #1, #2 and #3) reviewed for abuse: CNA A, as part of a CNA chat group, took a video recording of Resident #1, naked, in the shower having a bowel movement, with a close-up view of her exposed bottom with feces on it and he shared it with the chat group. CNA B, as part of a CNA chat group, took a digital picture of Resident #2, naked, in the shower with her back toward the camera and not aware of the photo and she shared it with the chat group. CNA C as part of a CNA chat group, took a photo of Resident #3 after he had fallen on the floor without pants on, and shared it with the chat group. The noncompliance was identified as PNC. The IJ began on February 5th and ended on February 6th 2024. The facility had corrected the noncompliance before the survey began. This deficient practice could affect residents who require assistance with ADL's and result in emotional abuse and…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · K2024-02-16 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of residents property for 3 residents (Residents #1, #2 and #3) out of 5 residents reviewed for abuse and neglect in that: CNA A, as part of a CNA chat group, took a video recording of Resident #1, naked, in the shower having a bowel movement, with a close-up view of her exposed bottom with feces on it and he shared it with the chat group. CNA B, as part of a CNA chat group, took a digital picture of Resident #2, naked, in the shower with her back toward the camera and not aware of the photo and she shared it with the chat group. CNA C as part of a CNA chat group, took a photo of Resident #3 after he had fallen on the floor without pants on, and shared it with the chat group. CNA D as part of a CNA chat group, failed to report the video of Resident #1. CNA E as part of the CNA chat group, failed to report 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · K2024-02-16 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to report abuse immediately but no later than 2 hours after the incident for 3 of 3 residents (Residents #1, #2, and #3) reviewed for reporting abuse and neglect in that: CNA H was informed about the abuse of Residents #1, #2 and #3 by CNA F of text chat group and did not report it to the Administrator until February 5th at 06:00 a.m. (8 hours later). CNA F, as part of the CNA chat group, failed to report the phone of Resident #2. CNA D, as part of the CNA chat group, failed to report the video of Resident #1. CNA E, as part of the CNA chat group, failed to report the photos of Resident #2 and Resident #3. The noncompliance was identified as PNC. The IJ began on February 5th and ended on February 6th 2024. The facility had corrected the noncompliance before the survey began. This failure could place the residents at further risk of abuse and neglect due to lack of reporting of incidents. The findings included : 1. 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · Dcited before2026-06-05 · 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 observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Residents #2) reviewed for comprehensive care plans in that: The facility failed to care plan Resident #2's abductor wedge that was needed for her after hospitalization care. This failure could place residents at risk for not receiving care interventions.The findings included A record review of Resident #2's admission record dated 6/3/2026 revealed an admission date of 8/16/2022 and readmission on [DATE] with diagnoses which included generalized muscle weakness. A record review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old female admitted for LTC with ADL. Resident #2 was assessed with a BIMS…

  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 · D2026-06-05 · 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 reviews the facility failed to ensure, in accordance with accepted professional standards and practices, complete, accurately documented, readily accessible, and systemically organized medical records for each Resident, for 1 of 4 residents (Resident # 2) reviewed for accurate records. The facility failed to obtain an order Resident #2's physician for the use of the abductor wedge. This failure could place residents at risk for receiving care interventions without physicians' orders. The findings included: A record review of Resident #2's admission record dated 6/3/2026 revealed an admission date of 8/16/2022 and readmitted on [DATE] with diagnoses which included generalized muscle weakness. A record review of Resident #2's quarterly MDS assessment dated [DATE] revealed that resident #2 was a [AGE] year-old female admitted for LTC with ADL. Resident #2 was assessed with a BIMS score of 03 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident…

  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 before2025-07-31 · 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 observation, 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 reviewed for kitchen sanitation. 1. 1 container of an orange juice cup was sitting on top of a box of orange juice and was partially opened. 2. A box of graham cracker tart shells was open and the individual shells were not covered. 3. A box of vanilla ice cream cups was open, not dated and contained cups that had opened and spilled out into the cardboard box. 4. A box of strawberries in the freezer was open and the plastic wrap around the strawberries was torn, exposing the strawberries to the air. 5. An individually wrapped glazed donut was in a plastic baggie with smeared marks at the top where the Date and Contents line was located. 6. An undated and unlabeled bag of red juice was located under the juice dispenser and was not connected to the dispenser. 7. The facility failed to store a mop in the proper position in the utility closet. These deficient practices could place…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-31 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #89) reviewed for privacy, in that: The facility failed on 7/30/2025 when CNA A and RA B did not completely close Resident #89's privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #89's face sheet, dated 07/30/2025, revealed an admission date of 12/09/2023 and, a readmission date of 10/03/2024, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood),Dysphagia (Difficulty swallowing), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood). Record review of Resident #89's Quarterly MDS assessment, dated 04/25/2025, revealed the resident had a BIMS score of 09, indicating she was moderately…

  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 · D2025-07-31 · 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 resident Minimum Data Set (MDS) assessment accurately reflected the resident's status for 2 (Resident #48 and Resident #84) of 5 residents reviewed for accuracy of assessments. 1.The facility failed to ensure Resident #48 was coded on his annual MDS assessment dated [DATE] as receiving an antipsychotic medication. 2.The facility failed to ensure Resident #84 was coded on his quarterly MDS assessment dated [DATE] as receiving an antipsychotic medication. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1.Review of Resident #48's admission sheet with an original admission date of 8/31/24 and a re-admission date of 7/16/25, showed a [AGE] year-old male resident with diagnoses including Dementia, Depression, Anxiety, Post Traumatic Stress Disorder, Cholecystitis (inflammation of the gallbladder, often caused 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-31 · 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, interviews, and record reviews, the facility failed to 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 disease and infection for 1 of 6 residents (Resident #86) reviewed for infection control, in that: While providing colostomy care for Resident #86, LVN C failed to use proper infection control. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #86's face sheet, dated 07/30/2025, revealed an admission date of 02/05/2025, and a readmission date of 05/01/2025, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus(high level of sugar in the blood),Dysphagia (Difficulty swallowing), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest), Hypothyroidism (under active thyroid),…

  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 · D2024-06-21 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each 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 observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the residents for 1 of 3 residents (Resident # 15) reviewed for call light. The facility failed to ensure. Resident # 15's call light was within reach. This failure could place residents at risk of achieving independent functioning, dignity, and wellbeing. Findings include: Record review of Resident 15's face sheet dated 6/18/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident # 15 had diagoses which included: Guillain-Barré syndrome, (is a rare neurological disorder that occurs when the body's immune system attacks the peripheral nervous system), Paraplegia (is a specific pattern in which you can't deliberately control or move your muscles) and Pulmonary hypertension (condition that occurs when blood…

  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 · D2024-06-21 · tag F0559 — isolated
  Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
  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 record review and interview, the facility failed to ensure the right to receive written notice of a room change before the change was made for 2 of 2 resident (Resident #41 & Resident #80) reviewed for resident room changes. The facility did not provide evidence that Resident #41 and Resident #80 was given a written notice of a room change before the resident was moved. This deficient practice could affect residents in the facility that are moved without required notification. The findings included: Record review of Resident #41's comprehensive MDS assessment, dated 06/14/2024 reflected a [AGE] year-old female admitted on [DATE] a primary diagnosis of Other encephalopathy (damage or disease that affects the brain) and assessed to have severe cognitive impairment. Record review of Resident #41's face sheet, dated 06/21/2024 listed Resident #41's RP as Resident #41's primary contact. Record review of Resident #80's quarterly MDS assessment, dated 06/03/2024, reflected a [AGE] year-old female admitted 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 · D2024-06-21 · tag F0565 — failed to support the resident council — isolated
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to demonstrate their response and rationale regarding the resident's council's grievances after group meetings concerning issues of resident care and life in the facility and provide a private space for residents' monthly council meetings for 1 of 1 resident council, in that: The facility failed to demonstrate their response and rationale for such response to the resident council's grievances. The facility failed to provide the resident council with a private space for their monthly meetings. This failure could place residents that participate in a resident council at risk of not having the right to their concerns and grievances followed through with. The findings included: During confidential interviews on 06/19/24 at 02:02 PM, residents stated grievances were not always followed up on and they were concerned the grievances they wrote were not being addressed. They stated they felt they could not make grievances without being reprimanded by staff. They expressed they were not aware they could have resident council meetings…

  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 · D2024-06-21 · 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 a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality for 1 (Residents #451) of 8 residents reviewed for baseline care plans. Resident #451's baseline care plan, dated 06/18/24, did not reflect any interventions for focus of at risk for falls. This deficient practice could affect residents admitted to the facility and result in missed or inadequate care. The findings included: Record Review of Resident #451's admission Record, dated 06/18/24, reflected a [AGE] year-old male admitted [DATE] with diagnoses to include fracture of left femur, difficulty in walking, abnormalities of gait and mobility, cognitive communication deficit, and need for assistance with personal care. Record Review of Resident #451's admission MDS assessment, dated 06/12/24, reflected a BIMS score of 13 out of 15, indicating cognitively intact.…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$14,611 in federal fines across 1 penalty.

• $14,611 — penalty dated 2024-02-16

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 12 rows in the source record cover these 7 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.

2 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 $1.0M 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