Woodland Park Nursing & Rehab

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

Met the expected recovery: 66.7% 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 21 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 0.16 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 100 beds and averages 57.6 residents a day — about 58% occupied, or roughly 42 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.94 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.16 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.81 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 2.71 hrs/resident/day on weekends vs 3.03 on weekdays — 11% thinner on weekends. RN hours go from 0.14 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%.

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

Inspection trend

Deficiencies are 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.

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

32 citations, most serious first. The 15 most serious are shown; the remaining 17 are one tap away and print in full.

• Immediate jeopardy · K2025-07-24 · 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 14 resident reviewed for infection control. (Resident # 3, #29, #37 and #54) The ADON failed to follow infection control procedures on 07/22/25 while providing wound care for Resident #3 who was on EBP. The ADON failed to follow infection control procedures on 07/22/25 after Resident #3's indwelling urethra catheter tubing disconnected from the urinary catheter bag tubing during wound care. The facility failed to ensure Resident #3 was placed in contact isolation on 07/22/25 and failed to ensure staff were made aware of Resident #3 requiring contact isolation until after surveyor intervention on 07/23/25. The ADON failed to follow infection control procedures on 07/22/25 while providing wound care for…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-07-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 14 (Resident #41) reviewed for quality of care. The facility failed to ensure NP and MD was notified of UA/C&S results for Resident #41 on 01/11/25. The facility failed to ensure a urologist appointment was made for Resident #41 when he was seen at ER on [DATE]. The facility failed to ensure follow-up with the hospital's UA/C&S results on 07/07/25.An Immediate Jeopardy (IJ) was identified on 07/23/2025 at 4:50 p.m. The IJ template was provided to the facility on [DATE] at 5:17 p.m. While the IJ was removed on 07/24/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-07-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 14 residents reviewed for pressure sore management. (Resident #54)The nursing staff failed to document an accurate skin assessment and treat Resident #54's wounds from admission [DATE] through 07/23/2025.This failure could place residents at risk of not receiving appropriate care leading to worsening skin condition.Record review of Resident #54's face sheet, dated 07/18/2025, indicated a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included diabetes (too much sugar in the blood), obesity (a condition of having too much body fat, which increases the risk of health problems), insomnia (sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or both), and PPM…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-04-24 · 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 provide supervision and assistance devices to prevent accident for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for accidents/supervision. * The facility failed to ensure Resident #1 had interventions in place that addressed Resident #1's Fall Risk Assessment which indicated he was a high risk for falls. Resident #1 had a fall and was sent to the emergency room for assessment. A CT scan of the neck determined he had a fracture of one of the cervical vertebrae. * The facility failed to ensure Resident #2 had interventions in place after she had 2 falls. * The facility failed to ensure Resident #3 had interventions in place that addressed Resident #3's Fall Risk Assessment which indicated she was a high risk for falls after she had a fall. An Immediate Jeopardy (IJ) was identified on 04/23/25 at 04:44 p.m. and the IJ template was provided to the Administrator. While the immediacy was removed on 04/24/25 at 02:50…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-06-12 · 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, interview, and record review, the facility failed to ensure each resident received adequate assistance to prevent accidents for 1 of 13 residents (Resident #32) reviewed for accidents. The facility failed to ensure the Van Driver transferred Resident #32 safely out of the facility transport van using the mechanical wheelchair lift. Resident #32 fell out of the facility van and sustained a hematoma (a collection of blood outside of a blood vessel, which is caused by injury or trauma) to the back of her head. This failure could place residents at risk of injuries. Findings included: Record review of a face sheet dated 06/11/24 indicated Resident #32 was an [AGE] year-old female, admitted to the facility on [DATE], and her diagnoses included acute pyelonephritis (a bacterial infection that causes inflammation of the kidneys), cirrhosis of the liver (chronic liver damage from a variety of causes leading to scarring and liver failure), muscle weakness, and difficulty walking. Record review of a…

  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 · Ecited before2026-06-10 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 5 of 5 residents (Resident #4, Resident #5, Resident #6, Resident #7 and Resident #8) reviewed for pharmacy services. The facility did not ensure accurate acquiring of Mounjaro (medication used to lower blood sugar-not insulin) for Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8. This failure could place residents at risk for drug diversion and being charged for medications not ordered by their physician. Findings included: Record review of an email dated 04/28/26 at 02:02 p.m. from the FNP to the Administrator indicated the FNP .was writing to bring to your immediate attention a serious medication ordering concern identified during a recent PCC order audit at your facility. The audit revealed that Mounjaro (tirzepatide) had been…

  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 · Fcited before2025-07-24 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours 7 days a week for 1 of 4 quarters of 2024 and 2025 (Quarter 2 - January 01, 2025, through March 31, 2025) PBJ reports reviewed for RN coverage. The facility did not have RN coverage for 01/16/2025. This failure could place residents at risk of lack of nursing oversight and a higher level of care.Findings included: Record review of the CMS PBJ reports indicated:Quarter 2 2025 (January 01, 2025, through March 31, 2025) there were no RN hours on 01/03/25 (Friday), 01/10/25 (Friday), 01/16/25 (Thursday), 03/15/25 (Saturday), and 03/16/25 (Sunday). During an interview on 07/23/2025 2:06 p.m., the DON said she filled out a handwritten time sheet when she worked the floor as the RN supervisor. She said she had to work shifts on the weekends when the scheduled RN was not able to work. She said the facility worked very hard to have an RN 8 hours a day 7 days a week. During an interview on 07/23/25 10:30 a.m., Administrator provided RN time sheets for 8 hours…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-07-24 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 2 meals (lunch) reviewed for palatability and temperature. The facility failed to provide food that was palatable and an appetizing temperature for 1 observed on 07/22/25 (lunch) meal. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Record Review of the daily menu dated on 07/22/25, indicated the lunch meal (A) items included Swiss steak with gravy, roasted potatoes, mixed veggie, and iced tea. During an observation on 07/22/25 at 11:00 a.m., the plate warmer cabinet was not plugged in to the power source. During an observation and interview on 07/22/2025 at 12:25 p.m., the test tray had Swiss steak with gravy, roasted potatoes, mixed veggie. The DM measured temperature of the roasted potatoes at 108 degrees and said not warm enough. She said the food should be at least…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-07-24 · tag F0580 — failed to tell family and doctor about changes — pattern
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consult with the physician regarding a change in condition for 3 of 14 residents reviewed for physician notification. (Residents #3, #6, and #40)The facility failed to consult physician for Resident #3, #6, and #40 when their BP medications were held for patterns of vital signs being outside the prescribed parameters.These failures could place residents at increased risk for complications due to delayed physician intervention. Findings included:1. Record review of Resident #3's face sheet, dated 07/22/25, reflected Resident #3 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included diabetes (too much sugar in the blood), morbid obesity (a disorder that involves having too much body fat), and hypertension (high blood pressure)Record review of the quarterly MDS assessment, dated 05/21/2025, reflected Resident #3 usually made herself understood and usually understood others. Resident #3 BIMS score was 13,…

  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 · E2025-07-24 · tag F0697 — failed to manage pain — pattern
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 14 (Resident #24) residents reviewed for pain. The facility failed to administer Resident #24's pain medication for scheduled doses on 04/27/25 at 10:00 p.m., 04/28/25 at 8:00 a.m., 2:00 p.m. and 10:00 p.m.Resident #24's pain was not assessed 41 of 90 scheduled times of pain intensity level assessments for April 2025. This failure could place residents at risk for increased pain and decreased quality of life. Findings included: Record review of the face sheet dated 07/24/2025 indicated Resident #24 was admitted on [DATE], he was [AGE] years old with diagnoses including muscular dystrophy (genetic diseases that cause progressive weakness and loss of muscle mass) and abnormalities of gait and mobility. Record review 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 · E2025-07-24 · tag F0805 — failed to prepare food in a form residents can eat — pattern
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 14 residents (Resident #28) reviewed for meals. The facility failed to ensure that Resident #28 was served meat and vegetables that were the proper texture. This deficient practice could affect residents by placing them at risk for choking and weight loss. The findings were: 1.Record review of Resident #28's admission record dated 07/24/25 indicated Resident #28 was admitted on [DATE], was [AGE] year-old female with diagnoses of severe intellectual disability (delayed motor, language and social accomplishments), anxiety disorder (intense excessive fear), cognitive communication deficit (difficulties in communication), and dysphagia oropharyngeal phase (difficulty swallowing that originates in the mouth). Record review of the physicians' orders indicated Resident #28 dated July 2025 indicated the diet order with start date of 03/14/25 was low concentrated sweets…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-07-24 · 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 under sanitary conditions for 1 of 1 main facility kitchen. The facility failed to ensure items stored in the refrigerator, and in the dry storage were labeled and discarded by the expiration date. The facility failed to ensure all staff wore hair restraints which covered all hair while in the kitchen. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations on 07/21/25 at 8:00 a.m., in the refrigerator revealed: white and yellow mushy substance in a 6 oz round container covered with tin foil in the fridge not labeled. 3 green jalapenos in a round 6 oz circle container uncovered and not labeled inside the refrigerator noted. During an interview on 07/21/25 at 8:20 a.m., [NAME] OO said the white and yellow mushy substance in a 6 oz round container covered with tin foil in the fridge not labeled and 3 green jalapenos in a round 6 oz circle container uncovered and not labeled should have not…

  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 before2025-07-24 · tag F0925 — failed to control pests — pattern
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  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 maintain an effective pest control program so that the facility is free of pests for 1 of 1 kitchen reviewed for environmental conditions. The facility failed to have pest control effectively treat the kitchen for flies on 07/22/25 during lunch meal. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life. Findings included: During an observation and interview on 07/22/25 at 11:35 a.m., Dietary staff JJ was cutting the pies and wrapping individual pieces for lunch, there were 3 flies flying around the prep area. A fly landed in the middle of the pie and DM saw the fly land on the pies, she went and stopped dietary aide JJ from using the pie the fly landed on. The DM placed the pie out of the way and said that will be thrown away. The DM said that every Friday the kitchen received groceries, and they fight flies several days after deliveries every week. The DM said she was not sure what else could be done for the flies. She said pest…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-24 · tag F0550 — failed to protect resident dignity and rights — isolated
  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 ensure residents received respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 14 (Resident #14 and Resident #28) residents reviewed for dignity.*The facility failed to ensure Resident #14 was treated with dignity and respect when CNA W told her in public to go to the bathroom before lying down in bed.*The facility failed to give and maintain dignity for Resident #28 by CNA N standing up assisting Resident #28 with feeding instead of sitting down to assist with feeding. This failure could negatively affect and impact residents' quality of life as a result of not giving residents respect and dignity. Findings included: 1. Record review of Resident #14's face sheet dated 07/23/25 indicated she was admitted on [DATE] and readmitted [DATE], was a [AGE] year-old female with diagnoses of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-24 · 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 record review and interviews, the facility failed to assure that each resident receives an accurate assessment reflective of the resident's status at the time of the assessment for Resident #54. The facility failed to ensure Resident #54's Nursing admission Assessment was complete and reflected the resident's status at the time of the assessment. Resident #54's Nursing admission Assessment was incomplete due to unanswered medical history information. This failure could place the residents at risk for not receiving the appropriate care and services. Record review of Resident #54's face sheet, dated 07/18/2025, indicated a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included diabetes (too much sugar in the blood), obesity (a condition of having too much body fat, which increases the risk of health problems), insomnia (sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or both), and PPM (permanent pacemaker - a small battery-powered medical…

  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

$31,330 in federal fines across 2 penalties.

• $18,915 — penalty dated 2025-07-24
• $12,415 — penalty dated 2024-06-12

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 GULF COAST LTC PARTNERS — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

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

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.

About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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