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Legend Oaks Healthcare and Rehabilitation - West S

222 Bertetti Dr, San Antonio, TX 78227 · For profit - Corporation · 124 certified beds · (210) 673-1700 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jun 20261 immediate-jeopardy citation$8,632 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • lower-than-typical staff turnover (21% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,632 in federal fines (most recent 2024-04-12)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
7323 Marbach Rd Ste 106 · (210) 231-2586 · Call to confirm hours
Pharmacy
Walgreens1.4 mi
9080 Marbach Rd · (210) 673-3082 · Call to confirm hours
Grocery
8111 Westshire Dr · (210) 675-5787 · Call to confirm hours
Park
3903 Crooked Trail · (210) 207-7275 · Typically dawn to dusk
Place of worship

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

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.9%15.8%15.4%better
Long-stay residents who lose too much weight3.9%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection3.1%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms3.9%2.4%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%3.3%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened36.3%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication11.9%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers1.6%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control14.2%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table3.6%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.3%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine98.1%88.0%79.4%better
Short-stay residents rehospitalized after admission31.8%25.7%22.6%worse
Short-stay residents with an outpatient ER visit10.9%12.3%12.0%typical
Long-stay hospitalizations per 1,000 resident days3.312.171.67worse
Long-stay outpatient ER visits per 1,000 resident days1.092.061.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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.

62.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.2%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
68.8%U.S. median 56.6%
Met the expected recovery
0.94U.S. median 0.31
Therapy hours / resident / day
0.39hours / resident / day
Physical therapy
0.43hours / resident / day
Occupational therapy
0.13hours / resident / day
Speech therapy

Met the expected recovery: 68.8% 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 32 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 0.94 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF62.2%CMS range 51.2–74.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.7–15.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge68.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge56.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge43.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting95.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.9%CMS range 4.9–13.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.971.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.53
RN hours/ resident / day
0.99
LPN hours/ resident / day
2.12
Aide hours/ resident / day
3.64
Total nurse hours/ resident / day
0.42
RN hoursweekends
20.7%
Total nursing turnover
18.2%
RN turnover

How full it usually is: this home is certified for 124 beds and averages 108.8 residents a day — about 88% occupied, or roughly 15 beds typically open. It runs fairly full. 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 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.20 hrs/resident/day on weekends vs 3.81 on weekdays — 16% thinner on weekends. RN hours go from 0.58 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 21% is below 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

6
deficiencies at the latest standard inspection (2026-01-29)
2
at the previous standard inspection (2024-10-31)

Deficiencies are more than at the previous inspection — worsening. 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.

ABCDEFGHIJKL

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.

20 citations, most serious first. The 11 most serious are shown; the remaining 9 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-04-12 · 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, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 5 residents (Resident #1 and Resident #2) reviewed for adequate supervision in that: The facility did not put in place adequate supervision for Resident #1 who had a history of suicidal ideations and a Major Depression diagnosis. On 03/21/24 at 10:30 AM, he was found slumped over on a W/C in his room after he tried to commit suicide by ingesting mouthwash. He was sent to the ER before law enforcement did an emergency detention for suicide attempt. The facility did not put in place adequate supervision for Resident #2 with a diagnosis of Major Depression and was not aware of items brought in from the outside that could pose a danger of self-harm for Resident #2. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 04/10/24 at 6:25 PM. While the immediacy was removed on 04/12/24, the facility remained out of compliance at a scope 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 · E2026-06-12 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #1) out of 6 residents reviewed for dignity. The facility failed to comply with Resident #1's request not to have CNA G assigned to her care and to not enter her room. This failure could place residents at risk of diminished dignity and affect their quality of life.The findings included: Record review of Resident #1's admission Record, dated 06/11/2026, revealed an [AGE] year-old female admitted [DATE] and re-admitted [DATE]. Resident #1 was listed as her own responsible party. Record review of Resident #1's Medical Diagnoses, undated and accessed 06/11/2026 at 3:54 p.m., revealed diagnoses including heart failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), hypertension…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-06-12 · 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 observation, interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported immediately but not later than 2 hours (for an injury of unknown origin involving serious bodily injury) or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 (Resident #1) out of 6 residents reviewed for abuse. The facility failed to report an alleged violation of verbal abuse of Resident #1 to the Administrator of the facility and the Administrator failed to report the violation of verbal abuse of Resident #1 immediately, but not later than 2 hours to other officials including to the State Survey Agency) in accordance with State law through established procedure.…

    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 · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #2) reviewed for urinary catheters. The facility failed to ensure CNA A performed proper catheter care for Resident #2 when she did not protect the catheter tubing from unnecessary tension while performing catheter care. This failure could result in the unintentional dislodgement of the urinary catheter or pain/injury to a resident's urinary tract. Findings included: Record review of Resident #2's Face Sheet dated 4/22/2026 reflected an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms (the inability or difficulty with urinating due to blockage of the urinary system). Record review of Resident #2's quarterly MDS submitted 3/4/2026 reflected a BIMS score of 09, which indicated 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-23 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #1) reviewed for infection prevention. The facility failed to ensure CNA B wore proper PPE while providing care to Resident #1 who had a catheter and was on enhanced barrier precautions. This failure could result in the spread of infection. Findings included:Record review of Resident #1's Face Sheet dated 4/22/2026 reflected an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms (the inability or difficulty with urinating due to blockage of the urinary system). Record review of Resident #1's quarterly MDS submitted 1/1/2026 reflected a BIMS score of 07, which indicated moderately impaired cognition. Section H0100 of the MDS…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-29 · tag F0641 — pattern
    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 assessment accurately reflected the resident's status for 3 of 6 residents (Resident #17, Resident #78, and Resident #108) who were reviewed for resident assessments. 1.The facility failed to correctly document Resident #17's use of insulin injections on the quarterly MDS assessment. 2.The facility failed to correctly document Resident #78's use of insulin injections on the quarterly MDS assessment. 3.The facility failed to correctly document Resident #108's use of insulin injections on the quarterly MDS assessment. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.The findings included: 1. Record review of Resident #17's admission sheet dated 11/13/2025 with an original admission date of 11/04/2020 documented a [AGE] year-old female resident with diagnoses including cerebral ischemia (insufficient blood flow to brain possibly…

    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 · E2026-01-29 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 2 of 7 nurse medication cart (200/300 hall medication cart and 300 hall nurse medication cart) and 1 of 4 Residents (Resident #148) reviewed for storage of drugs. 1. The facility failed to ensure an insulin pen in the 300-hall cart was dated with an open date once it was removed from the fridge and placed in the cart for use. 2. The facility failed to ensure the 300-hall nurse medication cart did not contain loose pills. 3. The facility failed to ensure the 200/300 medication hall cart did not contain a pill cutter with an unknown white residue. 4. The facility failed to ensure Resident #148 did not have medication in her room. These deficient practices could place residents at risk of medication misuse and diversion. The findings were: 1 and 2. Observation and interview on [DATE] at 8:46 a.m. the 300-hall nurse medication cart…

    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 · Ecited before2026-01-29 · 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, interview and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1.The facility failed to date food items in the kitchen pantry. 2.Dietary Aide F failed to correctly secure their hairnet in the kitchen. 3.The facility failed to date items in the nourishment refrigerator. 4.The facility failed to seal items in the kitchen freezer. This deficient practice could place residents at risk for food borne illness.The findings include: Observation on 01/26/2026 at 12:30 p.m., of the kitchen pantry revealed the following:-16 loafs of bread with no date,-1 box of clear fry oil with no date,-1 Ziploc bag of relish packets with no date,-1 Ziploc bag of salt packets with no date, and-1 Ziploc bag of individual packs of goldfish with no date. Observation on 01/26/2026 at 12:41 p.m., of the kitchen freezer revealed the following:-1 open bag of frozen sugar cookie dough and-1 open bag of French toast sticks. During an interview on 01/26/2026 at 1:15 p.m., the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-29 · 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 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 3 of 4 residents (Resident #96, #14, and #108) reviewed for infection control:1. a. The facility failed to ensure Resident #96's indwelling urinary catheter bag was not on the floor and CNA A wore the proper PPE while handling Resident #96's indwelling urinary catheter bag who was on EBP.b. The facility failed to ensure CNA C used appropriate hand hygiene between glove changes and when moving from a soiled area to a clean area when providing catheter/incontinent care to Resident #96.2. The facility failed to ensure CNA A used appropriate hand hygiene when moving from a soiled area to a clean area when providing catheter/incontinent care to Resident #14.3. The facility failed to ensure Resident #108's indwelling urinary catheter…

    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 · D2026-01-29 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 the transfer or discharge is documented in the resident's medical record, for 1 of 1 residents (Resident #123), in the facility reviewed for discharges. The facility failed to complete a discharge MDS for Resident #123. This failure could place residents at risk for inaccuracy of their health record.The findings include: Record review of Resident #123's admission sheet dated 09/25/2025 with an original admission date of 08/26/2025 documented an [AGE] year-old male resident with a primary diagnosis of chronic obstructive pulmonary disease (progressive lung disease making it harder to breathe). Record review of Resident #123's order summary included an admit to the facility with a verbal order which was discontinued with no end date and no discharge order. Record review of Resident #123's progress notes revealed a noted dated 09/30/2025 at 11:04 stating resident discharged home at approx. 1100am, picked up via a local transport…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-29 · 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

    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 7 medication carts (300 hall nurse medication cart) reviewed for medications and pharmacy services, in that: The facility failed to ensure the controlled drugs-count record was not signed prior to the shift change. This failure could place residents at risk for not receiving therapeutic effects.The findings included: During an observation and record review on 1/29/26 at 8:46 a.m., LVN D was observed to have pre-signed the controlled drugs-count record for the 3:00 p.m. to 11:00 p.m. shift. The controlled drugs-count record, dated January 2026, contained LVN D's signature in the section designated for the off going nurse for the 3:00 p.m. to 11:00 p.m. shift. The narcotic count had not yet occurred with the oncoming nurse at shift change at the time the signature was observed. During an interview on 1/29/26 at…

    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
Show the remaining 9 citations
  • Potential for harm · Dcited before2025-12-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 2 residents (Residents #1) reviewed for infection control:The facility failed to ensure CNA A utilized hand hygiene between glove changes during peri-care on Resident #1. This failure could place residents at-risk for infection due to lack of hand hygiene and could result in infection or illness.The findings included:Record review of Resident #1's face sheet dated 10/30/25 revealed a [AGE] year-old female admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses that included encephalopathy (general term used to describe any disease or disorder that affects the structure or function of the brain), memory deficit, Parkinson's disease (progressive neurological disorder that affects movement), muscle wasting…

    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 · F2024-10-31 · tag F0576 — widespread
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to promote the residents' right to receive mail, for all facility residents, in that: Facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. The findings were: During a confidential group meeting on 10/30/24 at 2:30 p.m., members of the resident group stated that they do not receive mail on Saturdays and stated they feel this practice was disrespectful. During an interview with the ADON on 10/31/2024 at 9:30 a.m., the ADON stated mail was not delivered to resident's on Saturdays, unless they came up to the receptionist and asked for their mail. During an interview with the ABOM on 10/31/2024 at 1:18 p.m., the ABOM stated he and the BOM did not work on Saturdays, and that the mail received at the facility on Saturdays were left for them to sort and was given to the residents on Mondays, unless the residents asked for their mail. During an interview with the Weekend Receptionist 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 · D2024-10-31 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation's, interview's, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 12 Residents (Resident #28) whose records were reviewed for care plan revision/timing: The facility failed to ensure Resident #28's care plan was revised the reflect use of locked box. These deficient practices could affect any resident and contribute to Residents not receiving the care and services they needed. The findings included: Record review of Resident #'s 28 face sheet , dated 10/29/24 , a 65 - year old male admitted to the facility on [DATE] with diagnoses that included Heart Failure ( occurs when the heart muscle doesn't pump blood as well as it should) , Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel and Unspecified Dementia ( a term used to describe a group of symptoms affecting memory, thinking and social abilities), Record review of Resident #28's quarterly 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-12 · tag F0609 — failed to report abuse allegations — isolated
    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 interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 5 residents (Resident #1) reviewed for reporting of suicidal attempt, in that: On 03/21/24, the facility did not report to the State Survey Agency (HHSC) (Health and Human Services Commission) a complaint of Resident #1 attempting suicide in the facility by ingesting mouthwash. This failure could place residents at risk for harm to include neglect, a diminished quality of life, and possible death. The findings included: Record review of facility's Abuse policy dated revised 10/2022 reflected: .Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Record review of facility's Reporting policy dated revised…

    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 · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-15 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    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 assess each resident quarterly (every 3 months) using the Minimum Data Set form specified by the state and approved by CMS for 1 of 36 residents (Resident #10) reviewed reviewed for quarterly assessments, in that: Resident #10's Quarterly MDS Assessment was not completed within 92 days of the previous quarterly assessment. This failure could place residents at-risk of not having their assessments completed timely. The findings were: Record review of Resident #10's face sheet, with a report date of 09/15/2022, reflected Resident #10 was admitted on [DATE] with diagnoses that included: muscle atrophy of left shoulder (breakdown of muscle in the left shoulder), dementia (A group of thinking and social symptoms that interferes with daily functioning), and pulmonary hypertension (A type of high blood pressure that affects arteries in the lungs and in the heart.) Record review of Resident #10's last MDS assessment revealed it was completed on 05/10/2023. 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-15 · 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 interview and record review the facility failed to refer a resident with newly evident or possible serious mental disorder for a PASRR Level II resident review upon a significant change of condition for 1 of 2 Residents (Resident #59) reviewed for PASRR (Preadmission Screening and Resident Review Services). The MDS Coordinator failed to refer Resident #59 for a resident review after being diagnosed with major depression, recurrent (04/02/21), major depressive disorder, recurrent, severe with psychotic symptoms (12/29/21) and schizoaffective disorder, (03/18/22). This deficient practice could place residents at risk of not receiving the needed PASRR services. The findings were: Review of Resident #59's Face Sheet dated 09/14/21 revealed Resident #59 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), schizoaffective disorder (a mental illness that can affect your thoughts, mood…

    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 · D2023-09-15 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 they transmitted a PASSR evaluation on newly admitted resident for 1 of 4 residents (Resident #69) reviewed for PASRR screenings. The facility failed to ensure that the initial PASRR screening (Level 1 Screening) was transmitted to the Local Mental Health Authority: This failure could place the residents at risk of not receiving specialized and/or habilitative services as need to meet their needs. Findings included: Record review of the clinical record for Resident #69 revealed he was a [AGE] year old male admitted on [DATE] with the diagnosis that included but not limited to the following: Major Depressive Disorder, recurrent, unspecified (feelings of low or depressed mood and/or decreased interest in pleasurable activities for prolonged and persistent time period), anxiety disorder (excessive anxiety and worry for more days than not maybe uncontrollable and for no specific rationale), post-traumatic stress disorder (may experience feelings 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-15 · 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 was possible for 1 of 32 residents (Resident # 5) reviewed for accidents and hazards. The facility failed to ensure Resident #5 did not have four disposable razors in the room. The failure could place residents at risk of harm or injury and contribute to avoidable accidents. The findings were: Record review of Resident #5's Face Sheet dated 09/14/2023, revealed an admission date of 12/05/2022 and readmission date of 09/11/2022 with diagnoses which included but not limited to the following: after care following joint replacement surgery, presence of left artificial knee joint, muscle wasting and atrophy(the wasting or thinning of muscle mass), not elsewhere classified, multiple sites, pain in the left knee, (the resident had a left knee replacement and required assistance to complete daily tasks for himself); unspecified dementia, mild with other behavioral disturbance…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 for 2 of 2 nourishment rooms reviewed for dietary sanitation in that: The facility failed to maintain the cleanliness of the ice maker found within the nourishment rooms. These failures could place residents at risk for foodborne illnesses such as norovirus. The findings included: Observation on 9/14/2023 at 1:39 PM, revealed Nourishment room [ROOM NUMBER] located by halls 100-400 to have contained an ice maker with white, grey, and black mass accumulation in and around the ice dispensing components. Observation on 9/14/2023 at 1:50 PM, revealed Nourishment room [ROOM NUMBER] located by halls 500-800 to have contained an ice maker with white, grey, and black mass accumulation in and around the ice dispensing components. Interview and observation on 9/14/2023 at 1:55 PM, the DM stated the Dietary Department shared the responsibility…

    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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$8,632 in federal fines across 1 penalty.

  • $8,632 — penalty dated 2024-04-12

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 →

RatingThis homeChain avg
Overall 3 of 53.2-0.2 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 3 of 52.7+0.3 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 341 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Bennett Hills Rehabilitation and Care CenterGooding, ID 1 of 5Broadway By The SeaLong Beach, CA 1 of 5Chatsworth Park Health Care CenterChatsworth, CA 1 of 5Clarion Wellness and Rehabilitation CenterClarion, IA 1 of 5Colonial Manor of RandolphRandolph, NE 1 of 5Durango Health And RehabilitationDurango, CO 1 of 5Fort Dodge Health and RehabilitationFort Dodge, IA 1 of 5Greater Southside Health and RehabilitationDes Moines, IA 1 of 5Hearthstone Health And RehabilitationSparks, NV 1 of 5Heritage Gardens Rehabilitation and HealthcareCarrollton, TX 1 of 5Hillcrest Health Care CenterHawarden, IA 1 of 5Lake Village Nursing And Rehabilitation CenterLewisville, TX 1 of 5Lakeside Rehabilitation and Care CenterCoeur d'Alene, ID 1 of 5Legend Oaks Healthcare And Rehabilitation - NorthAustin, TX 1 of 5Legend Oaks Healthcare And Rehabilitation - WaxahaWaxahachie, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, TX 1 of 5Madera Post Acute CenterEl Monte, CA 1 of 5Medallion Post Acute RehabilitationColorado Springs, CO 1 of 5Mesquite Post Acute CareLubbock, TX 1 of 5Millbrook Healthcare and Rehabilitation CenterLancaster, TX 1 of 5Misty Willow Healthcare and Rehabilitation CenterHouston, TX 1 of 5New Orange HillsOrange, CA 1 of 5Northeast Rehabilitation and Healthcare CenterSan Antonio, TX 1 of 5Northgate PlazaIrving, TX 1 of 5Oak View Health And RehabilitationConway, SC 1 of 5Oakwood Care And RehabilitationLakewood, CO 1 of 5Omaha Nursing and Rehabilitation CenterOmaha, NE 1 of 5Onion Creek Nursing and Rehabilitation CenterAustin, TX 1 of 5Park Manor Bee CaveBee Cave, TX 1 of 5Pelican Pointe Health And Rehabilitation CenterWindsor, CO 1 of 5Premier Care Center For Palm SpringsPalm Springs, CA 1 of 5Provo Rehabilitation and NursingProvo, UT 1 of 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5San Marcos Rehabilitation and Healthcare CenterSan Marcos, TX 1 of 5Sonterra Health CenterSan Antonio, TX 1 of 5SouthlandNorwalk, CA 1 of 5Southland Rehabilitation And Healthcare CenterLufkin, TX 1 of 5Spencer Post Acute Rehabilitation CenterSpencer, IA

Showing 40 of 341; lowest-rated first.

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

Owner / managerTypeRoleShareSince
DEWITT MEDICAL DISTRICTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 04/01/2017
GRAY, ROBERTIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/15/2017
MANSOOR, SAADIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/12/2023
ALEXANDER, ALMAIndividualCORPORATE OFFICERsince 05/27/2020
BURNAM, SOONIndividualCORPORATE OFFICERsince 04/01/2017
KEETCH, CHADIndividualCORPORATE OFFICERsince 03/01/2011
BERTETTI HEALTHCARE, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2017
ENSIGN SERVICES INCOrganizationADP OF THE SNFsince 05/01/2016
NATIONAL HEALTH INVESTORS, INC.OrganizationADP OF THE SNFsince 04/01/2017
TEXAS NHI INVESTORS, LLCOrganizationADP OF THE SNFsince 04/01/2017

CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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.

$13.5M
Net patient revenuemost recent cost report
+7.6%
Operating marginrevenue minus expenses
$1.2M
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 50%Medicare 5%Other / private 45%

This home reported $1.2M 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 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

$323per resident / day
operating cost
$9,831per month
≈ monthly operating cost
$350per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676312. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-29, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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