The Broadmoor at Creekside Park

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.

52.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 167 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 44.2% 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 77 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 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% 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 112 beds and averages 100.1 residents a day — about 89% occupied, or roughly 12 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.18 hrs/resident/day on weekends vs 3.58 on weekdays — 11% thinner on weekends. RN hours go from 0.51 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%.

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

Inspection trend

Deficiencies are unchanged from the previous inspection. 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.

29 citations, most serious first. The 14 most serious are shown; the remaining 15 are one tap away and print in full.

• Immediate jeopardy · J2026-03-13 · 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, record review, and interviews, the facility failed to ensure residents received adequate supervision for 1 of 7 residents (CR #1) reviewed for quality of care.CR #1 eloped from the facility on 02/23/2026 from an unwitnessed point of exit, and was located at the rear of the property at a school.The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 02/23/2026 and ended on 02/23/2026. The facility corrected the non-compliance before the investigation on 03/10/2026. The IJ template was provided to the Administrator on 03/12/2026 at 2:02pm.This failure could place the residents with exit seeking behaviors at risk for injury or death.Findings included:Record review of CR #1's undated face sheet, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnosis of unsteadiness on his feet, vascular dementia (decline in mental abilities), urine retention (buildup of urine), infection and inflammatory reaction due to indwelling…

  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 · Past Non-Compliance
• Immediate jeopardy · J2023-10-02 · tag F0697 — failed to manage pain — isolated
  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 observation, interview and record review, the facility failed to ensure pain management was provided to and monitored for 2 of 4 residents (Resident #128 and Resident #228), in that: -Resident #128 experienced pain after admission without her ordered Oxycodone available for use. -Resident #228 verbalized pain that without and pharmacological or non-pharmacological treatment offered to him. An Immediate Jeopardy (IJ) was identified on 09/27/2023 at 11:15AM. While the IJ was removed on 09/29/2023 at 06:37 PM, the facility remained out of compliance at a scope and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure caused Resident #128 and #228 to experience pain that went unmanaged and placed additional residents at risk for experiencing unmanaged pain. Findings include: Resident #128 Record review of Resident #128's face sheet revealed a [AGE] year old female who was admitted into the facility on [DATE] 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
• Immediate jeopardy · Jcited before2023-10-02 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the resident needs when the facility did not acquire the prescribed pain medications for 2 of 4 residents (Resident #128 and Resident #228) reviewed for medication administration, in that: -Resident #128 experienced pain after admission when her ordered Oxycodone was not available for use at the facility. -Resident #228 verbalized pain and was not offered pharmacological or non-pharmacological treatment to relieve his discomfort. An Immediate Jeopardy (IJ) was identified on 09/27/2023 at 11:15AM. While the IJ was removed on 09/29/2023 at 06:37 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure caused Resident #128 and #228 to experience pain that went unmanaged and placed additional residents at risk for experiencing unmanaged pain.…

  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
• Actual harm · Gcited before2024-04-19 · 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 residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices based on the comprehensive assessment of resident (Resident #1) 1 of 6 residents reviewed for quality of care. -The facility failed to ensure staff remained with Resident #1 after Resident #1 was found on the floor, bleeding from his head. -The facility failed to complete an appropriate assessment for Resident #1 after an unwitnessed fall, where a laceration to the head and skin tear to the shoulder were sustained. These failures could place residents at risk of not receiving needed care and services to meet their physical, mental, and psychosocial needs. Findings include: 1. Record review of Resident #1's face sheet dated 04/16/24, revealed he was admitted to the facility on [DATE] with diagnoses of idiopathic peripheral autonomic neuropathy (peripheral nerve damage); malignant…

  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 before2026-03-13 · 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, record review, and interviews, the facility failed to carry out activities of daily living necessary services to maintain grooming and personal hygiene reviewed for 2 of 7 residents (Resident #34 and Resident #123).The facility failed to ensure Resident #34 and Resident #123 received scheduled showers/bathing as required.This failure could result in skin breakdown, decreased self-esteem and quality of life.Findings included:Record review of Resident #34's undated face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnosis was fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing (healing fracture of right hip), falls, and muscle weakness.Record review of Resident #34's admission MDS assessment dated [DATE] revealed her BIMS score of 10 out of 15 indicated moderate cognitive impairment. Functional Abilities for Shower/bath and toileting hygiene revealed she required partial/ moderate assistance from staff…

  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 before2026-03-13 · 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, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 of 5 residents (Resident #40 and Resident #68) and one of three medication carts (300 hall nurse cart) reviewed for storage of medications.1. The facility failed to keep Resident #40's medications secured. Eight unidentified medication tablets were found in a medication cup inside Resident #40's mini refrigerator. Resident #40 did not have orders to self-administer medications.2. The facility failed to keep Resident #68's medications secured. One albuterol solution was found in the resident's purse. Resident #68 did not have orders to self-administer medications.3. An unlocked and unattended medication cart was observed in a hallway in front of a resident room.The deficient practice could place residents at risk of not receiving 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-13 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services 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 observations, interviews, and record review, the facility failed to ensure residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 resident (Resident # 124) reviewed for quality of care. The facility failed to ensure Resident #124's transportation arrangements were made for a dialysis (a medical procedure used to remove waste products and excess fluid from the blood when the kidneys are not functioning properly) appointment as physician ordered. Resident #124 missed a dialysis treatment on 3/10/26.This failure could affect residents who received transportation services for appointments, and place them at risk of complications and not receiving proper care and treatment to meet their needs. Findings included:Record review of Resident #124's face sheet dated 03/12/26 revealed she was admitted to the facility from the hospital on [DATE]. Her diagnoses included…

  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 before2026-03-13 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 for 1 of 6 residents (Resident #100) reviewed for pharmacy services. The facility failed to account for one of Resident #100's Alprazolam 0.5 mg tablets from 3/11/26 - 3/13/26.This failure could place residents at risk for drug diversion and/or duplicate therapy.Findings included: Record review of Resident #100's face sheet dated 3/13/26 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnosis included anxiety disorder, fracture of right pubis, and depression. Record review of Resident #100's admission MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15 which indicated intact cognition. Record review of Resident #100's Medication Administration Record for March 2026 revealed Alprazolam 0.5 mg was scheduled for 1 tablet every 8 hours as…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-13 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  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 medication error rate was not five percent or greater. The facility had a medication error rate of 7%, based on 2 errors out of 27 opportunities, which involved 1 of 6 residents (Resident #48) and 1 of 5 staff (MA G) reviewed for medication administration.MA G administered two anti-hypertensives, Amlodipine and Lisinopril, (medications that reduce blood pressure) to Resident #48 without checking her blood pressure according to MD orders, the pharmacy label, and facility policy on 3/11/26. This failure could place residents at risk of low blood pressure and hospitalization. Findings include:Record review of Resident #48's admission record dated 3/11/26 revealed an [AGE] year-old female who admitted on [DATE]. Her diagnoses included hypertension (high blood pressure), Alzheimer's disease, kidney failure, and hypertensive heart disease without heart failure (a condition caused by prolonged high blood pressure, leading 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-12 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, and comfortable environment for residents, staff, and the public for 2 (CR #1, Resident #1) of 5 residents and 2 (vacant room A, vacant room B) of 5 vacant rooms reviewed for sanitary conditions. 1. CR#1 was admitted on [DATE] into a room that had urine-stained sheets, brown fecal matter on the toilet seat and toilet bowl, and inside closet was wheelchair equipment left over from a previous resident. 2. Resident #1 had small black bugs crawling on the counter of the kitchenette inside her room on 12/12/25. 3. Vacant Room A had spider webs along the based boards, a urine stain on the fitted sheet, and dried fecal matter splatter inside of the toilet bowl on 12/12/25. 4. Vacant Room B had over 30 short black hairs found on the fitted sheet and hairballs and food particles along the baseboards on 12/12/25. These failures could pose a concern for infection control, sanitation, affect resident's quality of life.…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-20 · 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 interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (CR #1) reviewed for quality of care.-The facility failed to ensure a thorough head to toe skin assessment was completed on CR #1 on 8/29/25. CR #1 was discharged to an acute care hospital on 8/30/25 and was diagnosed with a left groin abscess.This failure could place residents at risk of delayed treatment, pain and infection.Findings Include:Record review of CR #1's admission record dated 11/10/25 revealed a [AGE] year-old male who admitted on [DATE] and discharged on 8/30/25 to an acute care hospital. His diagnosis included in part, Alzheimer's disease, pain, basal cell carcinoma of skin of left upper limb, and basal cell carcinoma of skin of right upper limb. (Basal cell carcinoma is a type of skin cancer).Record review of CR #1's quarterly MDS assessment…

  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 before2024-12-17 · 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 ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 out of 6 residents (Resident #40) reviewed for ADL care. - The facility staff failed to provide scheduled showers/baths to Resident #40 on 12/7/24 and 12/14/24. - The facility failed to change Resident #40's shirt for 3 days (12/15/24, 12/16/24, and 12/17/24) when there was debris and stains on it. These failures could place residents at risk of a decline in ADL's. Findings include: Record review of Resident #40's undated face sheet revealed he was a [AGE] year-old male originally admitted to the facility on [DATE], with the most recent admission date of 2/5/21. He had diagnoses of kidney failure (kidneys stop filtering the blood), dementia neurological conditions that cause a decline in mental abilities that affects daily life), hemiplegia (paralysis) 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
• Potential for harm · E2024-12-17 · tag F0842 — failed to keep accurate, complete medical records — pattern
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete, accurately documented, readily accessible, and systematically organized for 3 of 6 residents (Resident #151, Resident #18, and Residetn #27) reviewed for medical records. - The facility failed to document Resident #151's treatments into his electronic record from 12/14/24 to 12/15/24. - The facility failed to have current care plans for Resident #18 and Resident #27 in the electronic health system. This failure could cause missed treatments and a decline in health. Findings included: 1. Record review of Resident #151's face sheet dated 12/17/24 revealed a [AGE] year-old male who readmitted on [DATE]. His diagnosis included convulsions (rapid involuntary muscle contractions), malnutrition, and benign prostatic hyperplasia (an enlarged prostate). Record review of Resident #151's undated baseline care plan indicated he was lethargic…

  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 · D2024-12-17 · 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 that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 2 of 6 residents (Resident #18 and Resident #87) reviewed for catheter care. - The facility failed to ensure physician orders for catheter care were entered into the system for Resident #18 and Resident #87 and staff were unable to document care provided from 12/1/24 to 12/17/24. This failure could place residents with foley catheters at risk for urinary tract infections and skin break down. Findings included: 1. Record review of Resident #18's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses of a sacral pressure ulcer (pressure injury on the lower back and tailbone), diabetes mellitus (body does not produce insulin or resists it), quadriplegia (paralysis of upper and lower extremities), colostomy (an…

  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

“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

$46,833 in federal fines across 2 penalties.

• $10,361 — penalty dated 2026-03-13
• $36,472 — penalty dated 2023-10-02

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 CANTEX CONTINUING CARE — 37 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 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

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

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

Cost & finances

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

What families pay in TX