Wesley Woods Health & 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.

49.2% 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 58 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 9.5% 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 1.24 therapist hours per resident per day in 2026Q1 — more than 98% of the 13,892 homes that report any therapy hours at all.

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

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

Staffing

How full it usually is: this home is certified for 120 beds and averages 110.2 residents a day — about 92% occupied, or roughly 10 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 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.29 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 3.25 hrs/resident/day on weekends vs 3.61 on weekdays — 10% thinner on weekends. RN hours go from 0.15 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% 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 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.

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

• Immediate jeopardy · Kcited before2025-04-08 · 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 maintain accurate and timely medication records to minimize the potential for medication related adverse consequences or events for three (Resident #1, Resident #2 and Resident #3) of five residents reviewed for med errors. A medication error occurred on 11/28/2024 where residents # 1, #2 and #3 all received a double dose of their scheduled narcotic pain medication. Residents #1, #2 and #3 received their first dose at 7pm and the second dose at 8:30 pm. The nursing facility failed to: o follow their policy for medication administration to avoid errors. o document and monitor Residents #1, #2, and #3 after the medication errors to ensure no adverse effects o notify the Responsible Parties of Residents #1, #2, and #3 after medication errors An Immediate Jeopardy (IJ) was identified on 04/4/2025 at 5:50 pm and the facility was notified and given an IJ template. A revised template was provided on 4/7/2025 at 2:05 pm. While the IJ was removed on 04/8/2025…

  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 · G2024-06-13 · 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 interviews and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) out of seven reviewed for abuse. The facility failed to prevent abuse by failing to ensure Resident #1 was not pushed by CNA A resulting in a fall in his room on 5/27/2024. This failure placed residents at risk for abuse with potential for injuries, pain, trauma, and hospitalization. Findings included: Review of Resident #1's face sheet dated 6/12/2024 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Osteoarthritis left knee (arthritis of the knee), Alzheimer's Disease (progressive brain disorder that destroys memory and thinking skills), Age-related Macular Degeneration (degenerative condition of the eye affecting sight), Psychophysical visual disturbances (auditory/visual hallucinations/delusions), Hearing loss, Hypertension (high blood pressure), and Cerebrovascular Disease (problem with blood flow in the brain). Review of Resident #1's…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-02 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to respect the residents' right for 3 (Resident #1, Resident #27, and Resident #42) of 3 residents to send and promptly receive unopened mail, letters, and packages each postal delivery day. The facility failed to ensure Residents #1, #27, and #42 had the right to receive unopened packages. The failure could affect the rights of the facility's residents by opening their packages. Findings included: Review of Resident #1's face sheet dated 08/02/2023 revealed a [AGE] year-old-female with an admission date of 02/02/2019. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, bipolar disorder, unspecified, and personal history of malignant neoplasm of brain (a fast-growing cancer that spreads to other areas of the brain and spine). Review of Resident #1's most recent MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 14 suggesting…

  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 · Fcited before2026-03-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
  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 in accordance with professional standards for one of one kitchen reviewed for kitchen sanitation The facility failed to label, date, and seal food items in the pantry, refrigerator, and chest freezer on 3/19/2026. This failure could place residents at risk for health complications and foodborne illnesses.Findings included: During an observation on 3/19/2026, between 10:29 a.m. and 10:47 a.m., the following observations were made in the kitchen area: 1) an opened bag of cocoa was sitting on the pantry shelf with the top of the bag rolled down.2) an opened bag of cake mix was in a zip bag, but not labeled or dated on the pantry shelf3) an opened bag of lettuce mix was not sealed, labeled or dated on the fridge shelf4) a plastic container of a jello and fruitlike substance was not labeled or dated on the fridge shelf5) a metal container of cooked eggs was not labeled or dated on the fridge shelf6) a metal container of cooked breakfast meat was not labeled or dated 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-31 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  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 observations, interviews, and record review, the facility failed to provide each resident with a nourishing, attractive, palatable, temperature appropriate diet that met his or her dietary needs or preferences for 5 (Resident #13, #37, #53, #58, and #79) of 13 residents reviewed for dietary services.1. The facility failed to serve food that was appetizing.2. The facility failed to ensure food was served according to expected food temperatures.3. The facility failed to serve food that was adequately cooked in that residents were served raw and/or undercooked chicken, ground meat, and potatoes These failures placed residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. Findings include:Record review of Resident #13's face sheet on 12/31/2025 reflected an [AGE] year-old female with an original admission date of 4/8/2025 and readmission on [DATE] with diagnoses including Enterocolitis (inflammation in the inner lining of the small intestine and colon) from…

  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 before2025-12-31 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record reviews, the facility failed to store food, serve food at the correct temperatures, and sanitize equipment correctly in accordance with professional standards for foodservice safety in the reviewed 1 of 1 kitchen. The findings included:- Food items were not labeled and/or dated. - Food items were out of date. - Food items were not correctly sealed. - Dirty kitchen equipment. - Staff food items were kept with residents' food items. The failures could cause foodborne illness, particularly among vulnerable populations.Findings include:Observation on 12/29/2025 at 9:15 AM of the walk-in cooler reflected the following:- Heavy cream was in the original container, with an expiration date of 12-10-2025.- A plastic bucket of pickled eggs was uncovered and exposed.- A plastic bucket of pickles was uncovered and exposed.- Celery in a container with plastic wrap dated 12-23 with no expiration date. - A bag of greens was left open and exposed. - A box containing green squash had a moldlike substance on one of the squashes. - A package of strawberries…

  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 · Dcited before2025-12-31 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1of 2 Medication Storage rooms (Hall 300 Room) reviewed for drug storage. The facility failed to ensure expired medications were removed from the medication storage room on Hall 300 and that used dressings that were no longer sterile were also removed from the room. This failure could place residents at risk of receiving ineffective medication treatments and contaminated wound care that could result in unnecessary infections.Findings include: Observation on 12/30/25 at 2:37 pm of the 300 Hall Medication Storage Room revealed:2 Packages of 4x4 Sterile Wound Dressings opened but still in stock for use.1 Package of 4x4 Sterile Silver Wound Dressing opened but still in stock for use.1 Bottle of Zinc 50 milligram tablets expired 11/30/2025 In an interview on 12/31/25 at 1:31 pm CNA A stated, the policy for expired medications and expired/opened medical supplies was to throw them away. She stated that it was important to discard expired…

  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 before2025-12-31 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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 transmission of communicable diseases and infections for 1 of 1 laundry room. The facility failed to ensure laundry staff handled and stored linens in a manner to ensure cleanliness and protect from dust and soil to prevent cross-contamination and the spread of infections. This failure could place residents at risk for development of communicable diseases and infections that could diminish a residents' quality of life. Findings were: Observation on 12/30/2025 at 3:35 pm revealed 1 shelf of clean linen (resident gowns) stored on the dirty side of the laundry room. Resident gowns were folded, stacked neatly and appeared ready for use. The gowns were not covered or protected on the dirty side of the laundry. There was no signage giving directions on the use of the gowns. In an interview with 12/30/2025 at 3:40 pm LA C stated the laundry stored on the shelf…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-15 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and interviews, the facility failed to ensure a resident has a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 4 computers.On 08/14/2025 LVN A left the facility's computer open and unattended at the nurse's station with residents' personal medical information visible to anyone who passed by. The failure could place residents at risk of having their private information changed, viewed, and not kept secure. Findings include: During an observation on 08/14/2025 at 12:17pm reflected that LVN left her computer unlocked/opened and unsupervised, vaguely visible in an open area for resident and other individuals/guest of the facility passing by the nurse's station. At the time of the observation LVN was passing medication and approximately 35 feet away from the computer at the nurse station. During an interview with LVN A on 08/14/2025 at 12:17pm, the LVN A stated she was told it was ok to leave the computer screen unlocked with the resident's information displayed. The LVN A stated she did not remember…

  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 · E2025-06-24 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
  Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
  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, record reviews and interviews, the facility failed to provide each resident at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for three (Resident #1, Resident #3, and Resident #5) of 5 reviewed for timely meals. The facility failed to provide breakfast, lunch, and dinner according to the designated meal service schedules on multiple occasions. This deficient practice could place residents at risk of low blood sugar levels, increased stress levels, slowed metabolism rates, weakened immune systems, malnutrition, weakened hearts, and organ failures. Findings include: Interview on 06/24/2025 at 10:47AM with OMB revealed that lunch had been served late to the residents as late as 2PM while OMB was at the facility. OMB stated late meals had been served to residents more than once in the month of May and June. Observation on 06/24/2025 at 12:11PM revealed that lunch trays had…

  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 · Dcited before2025-06-24 · 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, interviews, and record reviews the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 5 residents (Resident #2) observed for resident rights. The facility failed to ensure Resident #2 was treated with respect and dignity when providing personal care for this resident. This failure could place residents at risk of lowered self-esteem, depression, and frustration. Findings included: Record Review of Resident #2's admission record revealed Resident #2 is an [AGE] year-old woman. Resident #2 was admitted to the facility on [DATE] with diagnosis of Alzheimer's Disease (a progressive brain disorder that slowly destroys memory and thinking skills, eventually impacting the ability to conduct even the simplest tasks), Depression and Anxiety Disorder. Record Review of Resident #2's care plan revealed. 1. Focus Area dated 07/10/2023, indicating Resident #2 has a history of resisting/refusing care and can become physically and verbally aggressive during care.…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-05-06 · 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 observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for three (Resident #1 and Resident #3) of five residents reviewed for pharmaceutical services.On 5/2/2025, two (2) medication cards - one from Resident #1 and one from Resident #3 - were observed with white tape on the reverse side of the card. The tape on the reverse side of the medication card indicated the potential for tampering. Administrative and nursing staff failed to be aware of patch use, failed to verify that the patches used were from the pharmacy, and failed to be trained on the use of patches to include when patches were acceptable for use in the facility policies and procedures.On 4/30/2025 during shift overlap, LVN-A and LVN-B discovered a narcotic count sheet reconciliation error. LVN-A noted on the count sheet the medication…

  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 · D2025-03-28 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care and treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for one of nine residents (Resident #1) reviewed for resident rights . The facility failed to notify Resident #1's responsible party when his labs result on 2/25/2025 indicated his lithium levels were out of range. This failure could place residents at risk of a lack of a dignified existence, self-determination and quality of life. Findings include: Record review of Resident # 1's face sheet, dated 3/28/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Traumatic Subarachnoid Hemorrhage (Brain bleed), Type 2 Diabetes (a blood…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“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

$55,900 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $55,900 — penalty dated 2025-03-19
• Medicare payment denial — starting 2025-05-08 for 8 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 CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY — 9 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 13 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

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