North Pointe 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.

35.5% 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 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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 126 beds and averages 48.3 residents a day — about 38% occupied, or roughly 78 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 3.15 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.67 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 2.82 hrs/resident/day on weekends vs 3.29 on weekdays — 14% thinner on weekends. RN hours go from 0.36 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 94% is well above 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.

25 citations, most serious first. The 15 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · Kcited before2025-09-11 · 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 observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for two of five residents (Resident #1 and Resident #2) reviewed for supervision. 1.) The facility failed to ensure Resident #1 was adequately supervised in order to prevent her from eloping from the facility. Resident #1, who was known to have confusion and wandering behaviors, first exited from an exterior door of the facility on 04/01/25. The facility failed to provide adequate supervision, and Resident #1 eloped from the facility on 09/06/25. 2.) The facility failed to ensure the Wander Guard system (an electronic system that could trigger alarms and lock monitored doors to prevent a resident from leaving unattended) utilized for Resident #2 was in proper working order. An Immediate Jeopardy (IJ) was identified on 09/10/25 at 1:50PM. The IJ template was provided to the facility on [DATE] at 2:08PM. While the IJ was removed on 09/11/25, 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-06-27 · 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 observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when Resident #2 physically assaulted her on 04/29/25 in Resident #3's room. The noncompliance was identified as PNC. The IJ began on 04/29/25 and ended on 05/05/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for abuse. Findings included: Record review of Resident #1's admission record, dated 06/26/25, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #1's Annual MDS Assessment, dated 03/17/25, reflected she had a BIMS of 03, indicating severe cognitive impairment. Her active diagnoses included non-traumatic brain dysfunction (refers to brain damage caused by factors…

  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 · Past Non-Compliance
• Immediate jeopardy · Jcited before2024-08-17 · 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 observation, interview, and record review, the facility failed to ensure residents were free from neglect for one of two residents (Resident #1) reviewed for suicidal ideation. The facility failed to put measures in place when Resident #1 admitted to the facility with the diagnosis of suicidal ideation. On 08/15/24, Resident #1 reported to facility that she drank hand sanitizer from a small pocket-sized bottle and wanted to kill herself. An IJ was identified on 08/15/24. The IJ template was provided to the facility on [DATE] at 3:48 PM. While the IJ was removed on 08/16/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal. The failure placed residents at risk for neglect. Findings included: Review of Resident #1's face sheet printed on 08/17/24 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included schizoaffective…

  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 · J2024-08-17 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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 develop and implement written policies and procedures that prohibit and prevent the neglect of residents for one of two residents (Resident #1) reviewed for neglect. The facility failed to implement the facility's written policies and procedures to prohibit and prevent neglect of Resident #1. The facility failed to put measures in place when Resident #1 admitted to the facility with the diagnosis of suicidal ideation. On 08/15/24, Resident #1 reported to facility that she drank hand sanitizer from a small pocket-sized bottle and wanted to kill herself. After administrative review, an IJ was identified on 08/29/24. The IJ template was provided to the facility on [DATE] at 4:31 PM. While the IJ was removed on 08/16/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal. The failure placed residents at risk…

  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 · J2024-08-17 · 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 interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for one of five residents (Resident #1) reviewed for baseline care plans. The facility failed to establish a base line care plan to address Resident #1's diagnosis of suicidal ideation when she admitted to the facility. On 08/15/24, Resident #1 reported to facility that she drank hand sanitizer from a small pocket-sized bottle and wanted to kill herself. An IJ was identified on 08/15/24. The IJ template was provided to the facility on [DATE] at 3:48 PM. While the IJ was removed on 08/16/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal. This failure place residents at risk of not having their needs met,…

  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 · D2026-06-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when 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 observations, interviews, and record review, the facility failed to ensure that residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #9) reviewed for oxygen orders. The facility failed to ensure Resident #9 was receiving oxygen at 2-4 liters per minute as ordered by the physician.This failure could place residents at risk of receiving incorrect or inadequate oxygen support, resulting in a decline in health.Findings included: Record review of Resident #9's Quarterly MDS assessment dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included acute and chronic respiratory failure, unspecified whether with hypoxia (low levels of oxygen in the body tissues) or hypercapnia (elevated carbon dioxide in the blood), tracheostomy status (an incision in the windpipe made to relieve an obstruction to breathing), respiratory failure, and hypertension (high 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-25 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  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 were free from significant medication errors for 1 of 5 residents (Resident #39) reviewed for medication errors.The facility failed to hold Resident #39's Carvedilol and Hydralazine per the recommended and prescribed heart rate parameters on 06/01/26, 06/04/26, 06/08/26, 06/12/26, 06/13/26, 06/14/26, 06/15/26, 06/16/26, 06/17/26, 06/20/26, 06/21/26, 06/22/26, and 06/24/26.This failure could place residents who receive blood pressure and pulse altering medications at an increased risk for complications such as decreased blood pressure, decreased pulse, and potential hospitalization.Findings included: Record review of Resident #39's Annual MDS, dated [DATE], reflected he was a [AGE] year-old male, who admitted on [DATE] with diagnoses that included: hypertension (high blood pressure). The MDS reflected Resident #39's cognition was intact with a BIMS score of 15. Record review of Resident #39's care plan, dated 05/04/26,…

  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 · E2025-04-17 · 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 3 of 18 residents (Residents #5, #20, and #34) reviewed for ADLs. 1. The facility failed to ensure Resident #20 and Resident #5's fingernails were cleaned and cut. 2. The facility failed to ensure Resident #34 received regular oral care. This failure had the potential to affect residents by placing them at risk for poor personal hygiene, decreased self-esteem, and a decline in their quality of life. Findings included: 1. Record review of Resident #20's Face sheet, dated 04/17/25, revealed the resident was a [AGE] year-old female with an admission date of 10/13/23 and readmitted on [DATE]. Record review of Resident #20's quarterly MDS assessment dated [DATE] reflected her diagnoses included atherosclerotic heart disease, dysphagia, chronic pain, and essential…

  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 before2025-04-17 · 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, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 2 residents (Resident #9 and #29) reviewed for quality of care. The facility failed to ensure Resident #9 and #29 wore their compression stockings, used to prevent swelling and blood clots, as ordered by the physician. This failure placed residents at risk of not receiving appropriate care and worsening of their conditions. Findings included: 1. Record review of Resident #9's quarterly MDS assessment, dated 03/27/25, revealed Resident #9 was an [AGE] year-old male with an admission date of 03/11/25 and readmission date of 03/22/25 with diagnoses which included edema and high blood pressure, and he had a BIMS score of 05, which indicated his cognition was severely impaired. Record review of Resident #9's care plan, dated 03/31/25, did not address edema 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 · E2025-04-17 · tag F0759 — failed to keep medication error rate low — pattern
  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 observations, interviews, and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater, 3 errors of 33 opportunities for errors leading to 9.09% medication error rates, for two of four staff (LVN D and MA F) observed for medication pass. The facility failed to ensure MA F administered the correct dose of 500mgs vitamin B12 for Resident #19. The facility failed to ensure LVN D administered all the crushed medication in the medication cups without leaving residue for Resident #105. These failures resulted in a 9.09% medication error rate and could put residents at risk who received medications via g-tube for tube occlusion, not receiving the correct dose of medication, and those that took orally not getting intended therapy. Findings included: 1. Record review of Resident #19's quarterly MDS Assessment, dated 03/26/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and readmission on [DATE]. Her BIMS…

  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 · D2025-04-17 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for one of 18 residents (Resident #36) reviewed for resident rights. The facility failed to ensure Resident #36 was treated with dignity and respect when she asked CNA C to dress her. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 03/05/25 and ended on 03/06/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for abuse and psychological harm. Findings included: Record review of Resident #36's Quarterly MDS Assessment, dated 04/2/25, reflected the resident was a [AGE] year-old female who initially admitted on [DATE] and re-admitted on [DATE]. Resident #36's diagnoses of hemiplegia or hemiparesis (paralysis or weakness to one side of the body), diabetes mellitus (disease that results in…

  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 · D2025-04-17 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  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 develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 1 (Resident ##9) reviewed for comprehensive care plans. The facility failed to develop a care plan for Resident #9's compression stockings. This failure placed resident at risk of not receiving appropriate care. Findings included: Record review of Resident #9's quarterly MDS assessment, dated 03/27/25, revealed Resident #9 was an [AGE] year-old male with an admission date of 03/11/25 and readmission date of 03/22/25 with diagnoses which included edema and high blood pressure, and he had a BIMS score of 05, which indicated his cognition was severely impaired. Record review of Resident #9's care plan, dated 03/31/25, did not address edema and compression stockings. Interview on…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-17 · tag F0687 — failed to care for feet properly — isolated
  Provide appropriate foot care.
  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 proper treatment and care to maintain good foot health by providing foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 18 residents (Resident #34) reviewed for foot care. The facility failed to ensure foot care, specifically trimming of toenails, was provided for Resident #34. This failure could result in residents developing fungal infections or other podiatric problems. Findings included: Record review of Resident #34's quarterly MDS, dated [DATE], reflected the resident was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE]. The MDS reflected the resident's diagnoses included hemiplegia or hemiparesis (paralysis or weakness to one side of the body), chronic kidney disease, stage 3 unspecified (longstanding disease of the kidneys leading to renal failure),…

  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 · D2025-04-17 · tag F0694 — isolated
  Provide for the safe, appropriate administration of IV fluids for a resident when 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 observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 2 residents (Resident #105) reviewed for intravenous fluids. The facility failed to ensure Resident #105's intravenous tubing was labeled with the date and initials. The failures could affect residents by placing them at risk for infections. Findings included: Record review of Resident #105's admission MDS Assessment, dated 04/11/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Her BIMS was not completed due to resident was newly admitted . Her diagnoses included cerebral infarction (stroke), and gastrostomy status (surgical opening into the stomach). Record review of Resident #105's care plan, dated 04/14/25, reflected the following: Focus: Resident #105 has potential fluid deficit rule out Dysphagia (difficulty swallowing) and g-tube status. Goal: Resident will be free of symptoms of dehydration…

  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 · D2025-04-17 · 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 observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely for 1 of 18 residents (Resident #10) on one hall reviewed for storage of medications. The facility failed to ensure an Amoxicillin tablet (an antibiotic) was not left at Resident #10's bed side unsupervised on 04/15/25. This failure could place residents at risk of consuming unsafe medications. Findings included: Record review of Resident #10's face sheet, dated 04/17/25, revealed the resident was a [AGE] year-old male with an admission date of 03/10/21 and readmitted on [DATE]. Record review of Resident #10's annual MDS assessment dated [DATE] reflected his diagnoses included unspecified dementia, depression, essential hypertension, and acute respiratory failure with hypoxia. Resident #10's BIMS score was 15 which indicated cognition was intact. Record review of Resident #10's physician order dated 04/11/25, revealed he had an order for Amoxicillin-Pot Clavulanate Tablet 875-125 MG…

  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

“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

$36,475 in federal fines across 3 penalties.

• $9,293 — penalty dated 2025-09-11
• $17,649 — penalty dated 2025-06-27
• $9,533 — penalty dated 2024-08-17

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 CREATIVE SOLUTIONS IN HEALTHCARE — 149 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

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

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.

About 72% 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