Seabreeze Nursing And Rehabilitation

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.

Therapy staffing: this home’s payroll records show 0.73 therapist hours per resident per day in 2026Q1 — more than 93% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 107 beds and averages 56.9 residents a day — about 53% occupied, or roughly 50 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 2.99 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 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 2.78 hrs/resident/day on weekends vs 3.08 on weekdays — 10% thinner on weekends. RN hours go from 0.34 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

41 citations, most serious first. The 18 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · Kcited before2024-10-16 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from abuse, neglect, exploitation or mistreatment for 5 of 73 residents (Resident #8, Resident #12, Resident #18, Resident #20, and Resident #30) reviewed for abuse and neglect in that: The facility failed to ensure residents at the facility were provided with hot water and baths/showers for a month, that would allow them to maintain cleanliness and access to activities of daily living. The facility negelcted to provide hot water in the facility for over a month. The residents in the building had not had showers in weeks and there was no documentation to show that residents had a bed bath or a shower for the month of September. -The facility neglected to ensure residents at the facility were relieved from filth, and distress. -Resident #8 had cried to staff about her discomfort of not having a bed bath or shower in weeks. -Resident #12 was diagnosed with the need for assistance with personal care. She had a urinary tract…

  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
• Immediate jeopardy · Kcited before2024-10-16 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  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 the necessary services to maintain grooming and personal care for 5 (Resident #8, Resident #12, Resident #18, Resident #20, Resident #30) of 73 residents reviewed for ADL care, in that: The facility failed to ensure residents at the facility were provided with hot water and baths/showers for a month, that would allow them to maintain cleanliness and access to activities of daily living. There had been no hot water in the facility for over a month. The residents in the building had not had showers in weeks and there was no documentation to show that residents had a bed bath or a shower for the month of September. -Resident #8 had cried to staff about her discomfort of not having a bed bath or shower in weeks. -Resident #12 was diagnosed with the need for assistance with personal care. She had a urinary tract infection and had not taken a bed bath or shower in a month. -Resident #18 had been diagnosed with a skin rash and other…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-04-30 · tag F0773 — pattern
  Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to obtain laboratory services when ordered by a physician in accordance with the State law, including scope of practice laws for 1 of 12 residents (CR #1) reviewed for laboratory services. 1. LVN A failed to document physician's orders and obtain weekly laboratory services (CMP, CBC, and CPK) as ordered by CR #1's infectious disease physician when she was discharged from an acute care hospital on [DATE] and resulted in re-hospitalization on 04/16/2024 with elevated WBC values, which indicated infection. 2. LVN A failed to document physician's orders and obtain weekly laboratory services (BMP and CBC) as ordered by CR #1's NP when she reconciled (the process of comparing a patient's medication orders) medication orders on 03/29/2024 and resulted in re-hospitalization on 04/16/2024. She was diagnosed with polymicrobial (multiple bacteria) skin and soft tissue infections and multifocal (having more than one location) osteomyelitis of 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-03-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to ensure each resident received adequate supervision to prevent accidents for 4 of 17 residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for smoking. 1. The facility failed to ensure Resident #1 had proper supervision after her smoke assessment stated she was careless with smoking materials and dropped ashes on herself. Her care plan stated she needed an extender and apron to be safe. She was observed without supervision, an apron or extender. 2. The facility failed to ensure Resident #2 had proper supervision after he was found smoking in his room located in the memory care unit. He was supposed to be supervised by his family member. His family member was not supervising him upon observation. 3. The facility failed to ensure Resident #3 had supervision after she was deemed non-compliant with smoking and had placed a half-smoked cigarette, she had just extinguished into a brown paper bag. 4. The facility failed 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-03-25 · tag F0926 — failed to keep the home smoke-free / fire-safe — pattern
  Have policies on smoking.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to follow their own established smoking policy for 3 of 21 residents (Resident #1, Resident #2, and Resident #3) reviewed for smoking and compliance. 1. The facility failed to effectively intervene or follow their own smoking policy when Resident #1 was known to drop cigarette ashes on herself. 2. The facility failed to implement their own policy when resident #2, a memory care resident had smoked in his room. 3. The facility failed to implement their own policy when Resident #3 was known to be non-compliant and placed a half-smoked cigarette that she had just extinguished into a paper bag. These failures placed smoking residents at risk for injury from burns and fires caused by hazardous smoking behaviors. Findings Included: Record review of Resident #1's face sheet dated 2/28/2024 revealed she was a [AGE] year-old female who was admitted on [DATE]. She was diagnosed with anoxic brain damage(a brain injury due to restriction on the oxygen…

  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
• Immediate jeopardy · Jcited before2023-07-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 resident (Resident #70) of 18 reviewed for abuse. The facility failed to ensure Resident #70, who was cognitively impaired, had a history of aggressive behaviors, and resided in the facility's memory care unit, was free from abuse when she was observed yelling and screaming for TNA A and TNA B to stop when they were twisting her around naked in her wheelchair with her feet up in the air on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:40 p.m. The IJ template was provided to the facility on [DATE] at 5:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed cognitively impaired residents at risk of physical harm, emotional distress, mental…

  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
• Immediate jeopardy · J2023-07-23 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  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 have evidence that all alleged violations of abuse or mistreatment were thoroughly investigated and prevent further potential abuse or mistreatment while the investigation was in progress for 1 of 18 residents (Resident #70) reviewed for abuse. The Administrator, who was the facility's abuse coordinator and was responsible for investigating and reporting abuse incidents, failed to thoroughly investigate and report an allegation of abuse in the facility's locked memory care unit when Resident #70, who was cognitively impaired and had a history of aggressive behaviors, was observed yelling and screaming for TNA A and TNA B to stop when they were twisting her around naked in her wheelchair with her feet up in the air on [DATE]. The facility's administration failed to initiate protective interventions and continued to allow TNA A to provide care for Resident #70 ([DATE]) after the abuse incident. An Immediate Jeopardy (IJ) was identified 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Hcited before2024-10-16 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plane, and the resident's choices for 1 (Resident #18) of 73 residents reviewed for quality of care. The facility failed to apply compression wraps to Resident #18's legs as ordered and Resident #18 experienced increased swelling and discomfort in her lower extremities. This failure placed resident at risk for further injury or harm. Findings include: Record review of medical records indicated Resident #18 was a [AGE] year-old female admitted on [DATE] with the following diagnoses: Type 2 diabetes mellitus with diabetic neuropathy, unspecified (Primary, Admission), Dry eye syndrome of bilateral lacrimal glands, Pain in right leg, Localized swelling, mass and lump, right lower limb, and Varicose veins of right lower extremities. Record review of the MDS dated [DATE] Record review of the care plan…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-05 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from misappropriation of property and exploitation for 1 (Resident #1) of 8 residents reviewed for misappropriation and exploitation.The facility failed to ensure that Resident #1 was free from exploitation as evidenced by CNA A misappropriating funds from Resident #1's payment application. This failure could place residents at risk of misappropriation of property, financial hardship, and mental and emotional distress.Findings included: Record review of Resident #1's face sheet, dated 3/5/26, revealed the resident was a [AGE] year-old male, admitted [DATE], with diagnoses including cerebral infarction (stroke) and unspecified glaucoma (eye disease that gradually deteriorates vision by causing damage to the optic nerve). Record review of Resident #1's quarterly MDS, dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 11 that indicated moderate cognitive impairment. Record review of Resident 1's bank statement…

  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 · Ecited before2026-01-08 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Food items were observed stored in the facility refrigerator without proper sealing. This failure could place residents who received meals from the main kitchen at risk for food borne illness. Findings included: Observation on 1/6/2026 at 8:32 am revealed one 1-gallon full container of ranch dressing with visible food residue and buildup on the exterior surfaces including the lids and surrounding container. Observation on 1/6/2026 at 8:33 am revealed one 1-gallon full container of soy sauce with buildup on the exterior surfaces including surrounding container. In an interview with The Dietary Manager on 1/7/2026 at 3:40 pm. She said it was important to wipe each container completely after use to ensure the date was clearly visible on each container. She said it was her responsibility to ensure food items were cleaned, dated, and labeled. She said all kitchen staff were responsible…

  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 · D2026-01-08 · 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 The facility failed to ensure, when a discharge was anticipated, to complete a discharge summary, including but not limited to, a recapitulation of stay, a reconciliation of pre-discharge medications, a final summary of the residents' status, and post-discharge plan of care Based on observation, interview and record review, the facility failed to ensure, when a discharge was anticipated for 1 of 3 residents reviewed for discharge summary (Resident # 60). --the facility failed to complete a discharge summary for Resident #60. This failure could place residents at risk of incomplete discharge records.Findings include: Record review of Resident #60's face sheet revealed admission date 7/15/25 with diagnoses including cerebral infarction (disruption of blood flow to brain), carotid artery syndrome (plaques clog blood vessels that deliver blood to the brain), Meniere's disease (inner ear disease), heart disease (conditions affecting the heart and blood vessels), Parkinsonism (neurological condition causing…

  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 · D2026-01-08 · 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 ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 5 residents (Resident #44) reviewed for PASRR.The facility failed to ensure that Resident #44's PASRR screening was updated accurately as evidenced by Form 1012 not being completed and submitted in a timely manner.These failures could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.Findings included:Record review of Resident #44's face sheet dated 1/8/26, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including unspecified dementia (group of symptoms affecting memory, thinking and social abilities), unspecified severity, with mood disturbance. Record review of Resident #44's quarterly MDS dated [DATE], section C revealed a BIMS score of 11 that indicated cognition…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-08 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care or 1 or 1 resident (Resident #57) reviewed. The facility failed to complete the baseline care plan within the required 48-hour timeframe following admission for Resident #57. This failure could place the residents at risk for unmet care needs due to inconsistent care, or failure to receive required services.Findings included: Record review of Resident #57's electronic admission record undated revealed she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included Malignant neoplasm of right main bronchus (cancer located in the right main bronchus, which is one of the large airways that carries air from the trachea into the right lung), adult failure to thrive, pressure ulcer of sacral region, unstageable( pressure injury cannot be assigned a stage because the base of the wound is not visible).…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-08 · 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 interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for 1 (Resident #61) of 5 residents reviewed for care plan.The facility failed to ensure that Resident #61's care plan was reviewed and revised regarding her weight changes and reflected both weight gains and losses.This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being.Findings included:Record review of Resident #61's face sheet dated 1/8/25, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including other encephalopathy (any condition that disrupts the normal functioning of the brain).Record review of Resident #61's quarterly MDS dated [DATE], section C revealed a BIMS score of 13 that indicated cognition was intact (13-15). No weight loss or weight gain of 5% or more in the last month or loss 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 before2025-02-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, and record review the facility failed to ensure the residents were being properly supervised to prevent accidents and hazards. The facility staff failed to ensure resident's environment was safe and free from any potential harm. LVN-B did in fact bring in a weapon namely a pellet gun into the facility. The facility failed to ensure that facility staff were trained on how to properly ensure the resident environment remains as free of accident hazards as possible. Findings include: Record review of Resident #1's care plan dated 12/05/2024 revealed Resident#1 was care planned for falls and that his medication should be administered to him as prescribed by his physician. In an interview with CNA-A on 02/06/25 at 11:50am CNA-A said that on 02/05/25 on the overnight shift she asked LVN B if she had the keys to the CMA medication cart. CNA-A said that LVN-B told her no and that when CNA-A said that she saw LVN-B sticking something in her pocket. CNA-A said she asked LVN-B what you put in your pocket. CNA-A said that's when LVN-B put a gun on the counter and said this is…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-07 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure that Resident#1 medications were properly stored. The facility staff failed to ensure that resident's medication was stored and secured in a secure manner. LVN-A did not secure her keys, nor did she ensure that the med room was secure. As a result, Norco drugs were unaccounted for. This failure could place residents at risk of not having their prescribed medications given to them as directed according to physician orders. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included major depressive disorder, bipolar disorder, dementia, shortness of breath, and congestive heart failure. Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 01/11/25, section C revealed a BIMS (Brief Interview for Mental Status) score of 14. Record review of Resident #1's care plan dated 12/05/2024 revealed Resident#1 was care planned for falls and that his…

  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 before2024-10-16 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 9 of 61 days reviewed for staffing, in that: There was no proof of RN coverage for 9 days of 61 days reviewed for RN coverage. This failure placeds all residents at risk of not receiving adequate medical care and supervision of an RN. Findings included: Record review of the facility's RN staffing hours from the period of 04/01/24 through 06/31/24 revealed there was no proof of RN coverage for the following days 05/17/24, 05/18/24, 05/20/24, 05/21/24, 5/22/24, 05/23/24, 05/24/24, 05/31/24 and 06/01/24. Record review of CMS PBJ report revealed the facility had no RN coverage [NAME] 04/06/24, 04/07/24, 04/16/24, 04/19/24, 04/21/24, 05/17/24, 05/18/24, 05/20/24, 05/21/24, 5/22/24, 05/23/24, 05/24/24, 05/31/24 and 06/01/24. During an interview with the facility Administrator on 09/05/24 at 2:00 p.m., he said the PBJ report was wrong. He said there was an RN…

  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 · F2024-10-16 · tag F0908 — failed to keep essential equipment working — widespread
  Keep all essential equipment working safely.
  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 all mechanical, electrical, and patient care equipment (boiler room equipment) in safe operating condition for 1 of 1 hot water heater heaters system in the facility in that - The facility did not have hot water for resident's use in two weeks . This failure could place the residents at risk of not having their ADL care in a timely manner and as needed. Findings included: Interview and observation on 09/23/24 at 1:28 p.m ., revealed the facility did not have hot water for resident's use. During an interview, Resident #12 said she did not want to take shower with cold water. She said the facility had no hot wat ER and she had not had her showers for about two to three weeks. She said she only have bed baths. Observation on 09/23/24 at 1:30 PM revealed there are two shower rooms on hall 100. The water for the shower room was turned on for 5 minutes. The water was lukewarm at 84 degrees Fahrenheit-F). During an interview on 09/23/24 at 1:45 PM, CNA K she said she had did not given resident showers…

  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

“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

$146,420 in federal fines across 2 penalties. 2 Medicare payment denials on record.

• $120,426 — penalty dated 2024-10-16
• $25,994 — penalty dated 2024-03-25
• Medicare payment denial — starting 2024-11-15 for 2 days
• Medicare payment denial — starting 2024-04-24 for 7 days

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

Part of a chain

This home belongs to SLP OPERATIONS — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 10 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 77% 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

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

What families pay in TX