Peach Tree Place

Location & what’s nearby

Open in Google Maps ↗ · Directions ↗ · Larger map ↗

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

Quality measures — how residents actually fare

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

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

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

Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 59 beds and averages 35.6 residents a day — about 60% occupied, or roughly 23 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.65 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.33 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 2.29 hrs/resident/day on weekends vs 2.80 on weekdays — 18% thinner on weekends. RN hours go from 0.53 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 92% 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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

28 citations, most serious first. The 15 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · J2025-09-19 · 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 protect the resident's right to be free from abuse and neglect for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to protect Resident #1 from abuse when four facility staff (LVN A, RN B, NA C and Laundry Staff D) grabbed Resident #1 and forcibly carried him by his extremities and dragged him on the floor to his room. The staff placed Resident #1 in his room and held the door closed so that he could not leave his room. An Immediate Jeopardy was identified on 8/25/25. The IJ template was provided to the facility on 8/25/25 at 5:07 PM While the IJ was removed on 8/26/25, the facility remained out of compliance at a scope of isolated, and a severity level of no actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure could place residents at risk of physical injury, psychological trauma, and severe emotional distress. Findings include: Record review of…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-09-19 · tag F0603 — failed to not confine residents against their will — isolated
  Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
  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 protect the resident's right to be free from involuntary seclusion for 1 of 7 residents (Resident #1) reviewed for involuntary seclusion. The facility failed to ensure LVN A, RN B, N/A C, and Laundry Staff D did not isolate Resident #1 as a method of addressing his behaviors. The staff placed Resident #1 in his room and held the door closed by the doorknob so that he could not leave his room as he struggled to get the door open and leave the room. An Immediate Jeopardy was identified on 8/25/25. The IJ template was provided to the facility on 8/25/25 at 5:07 PM While the IJ was removed on 8/26/25, the facility remained out of compliance at a scope of isolated, and a severity level of no actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure affected Resident #1 and could place residents with behavior healthcare needs at risk of injury and isolation, leading to a decreased quality of…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-09-19 · tag F0604 — failed to not use physical restraints improperly — isolated
  Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  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 protect the resident's right to be free from physical or chemical restraints imposed for purposes of discipline or convenience, and that are not required to treat the resident's medical symptoms for 1 of 7 residents (Resident #1) reviewed for physical restraint/chemical restraints. The facility failed to protect Resident #1 from physical restraint when LVN A, RN B, N/A C, and Laundry Staff D grabbed Resident #1 by his arms and legs which restricted his movement and dragged the resident across the floor and carried him by holding onto his arms and legs down to his room. The staff placed Resident #1 in his room and held the door closed so that he could not leave his room. An Immediate Jeopardy was identified on 8/25/25. The IJ template was provided to the facility on 8/25/25 at 5:07 PM While the IJ was removed on 8/26/25, the facility remained out of compliance at a scope of isolated, and a severity level of no actual harm, due to 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-09-19 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  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 implement policies and procedures for reporting when the administrator and the State Survey Agency were not notified immediately notified of abuse on 8/17/25 when 4 facility staff (LVN A, RN B, NA C, and Laundry attendant D) grabbed Resident #1 and forcibly carried him by his extremities to his room. The staff placed Resident #1 in his room and held the door closed so that he could not leave his room. The abuse was not reported to the administrator until 8/19/25. This failure could place residents at risk of physical injury, psychological trauma, and severe emotional distress.An Immediate Jeopardy was identified on 9/12/25. The IJ template was provided to the facility on 9/12/25 at 5:07 PM While the IJ was removed on 9/14/25, the facility remained out of compliance at a scope of isolated, and a severity level of actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions. Findings include: A record…

  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 · Jcited before2025-09-19 · 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 a comprehensive person-centered care plan for each resident , consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment which were to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to implement de-escalation techniques listed on the care plan were not implemented when 4 facility staff , (LVN A RN B, NA C and Laundry staff D) grabbed Resident #1 and forcibly carried him by his extremities to his room. The staff placed Resident #1 in his room and forcibly held the door closed so that he could not leave his room. An Immediate Jeopardy was identified on 9/12/25. The IJ template was provided to the facility 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 · Dcited before2026-04-18 · 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 interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan 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 2 of 7 residents (Resident #1 and, Resident #5) reviewed for care plans. The facility failed to ensure the comprehensive care plan for Resident #1 addressed a fall, preferences, and discharge planning. The facility failed to ensure the staff developed the comprehensive care plan goals and interventions from the comprehensive assessment for Resident #5 to address nutrition, dental, pressure ulcer, communication, ADL function/rehabilitation potential, and discharge planning. This failure could place the residents at risk of inadequate care and services.Findings included: Record review of Resident #1's face sheet dated 4/18/2026 revealed a [AGE] year-old female with an admission date…

  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 · E2025-09-19 · tag F0940 — failed to train staff — pattern
  Develop, implement, and/or maintain an effective training program for all new and existing staff members.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record reviews and interviews the facility failed to develop implement and maintain an effective training program for all new and existing staff individuals providing services under a contractual management and volunteers consistent with their expected roles for 2 of 12 employees (LVN A and RN B) reviewed for required training. The facility failed to ensure LVN A and RN B had annual dementia and restraint reduction training. This failure could place residents at risk of receiving care from individuals who have not been properly trained. Findings include: Record review of employee training files reflected LVN A was hired 3/1/24 and her last dementia training was dated 3/15/24 . There was no evidence of restraint reduction training in her file other than a copy of a restraint reduction policy that was signed on 10/13/24. Record review of RN B's Employee files reflected the date of hire as 1/16/25. Ungraded dementia test dated 1/16/25. No restraints training. During an interview on 8/23/25 at 1:30 PM, LVN A stated Everyone that works in that building has had training for…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-19 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately inform the resident/resident representative and consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights. The facility failed to ensure LVN A and LVN E communicated to the physician and POA a change in Resident #1's behavioral status that led to a change in his treatment regimen.The facility failed to ensure that RN NB communicated to the physician and the POA a change in Resident#6's health status that led to a change in his treatment regimen. This failure could place residents at risk of unmet physical and psychosocial needs, physical harm and a decrease in quality of life. The findings included: The findings included: Record review of Resident # 1's face sheet dated 8/24/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: major depressive…

  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 before2025-05-15 · tag F0656 — failed to write and follow a full care plan — pattern
  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 interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 (Residents # 21, #25, and #145) residents reviewed for comprehensive care plans. The facility failed to ensure Resident #21 had a care plan in place regarding hospice services. The facility failed to ensure Resident #25 had a care plan in place regarding her diagnosis of seizure disorder. The facility failed to ensure Resident #145 had a care plan in place regarding his DNR status. These failures could place residents at risk for not receiving appropriate care and supervision. Findings included: Record review of Resident #21's admission Record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of cerebral infarction due to thrombosis of right middle cerebral…

  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 · Ecited before2025-05-15 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, by failing to ensure: A. The food fryer was left in an unsanitary condition, food fryer had not been cleaned after use, food crumbs dried to fryer baskets (2) and inside fryer walls. B. Bottom shelf of food prep table was not clean and hads food crumbs on shelf and food crumbs on container lids containing flour, sugar and powder milk that wasis stored on shelf. These failures could place residents at risk for decline in nutritional health status and foodborne illness. The findings include: On 5/13/25 at 9:34am during the observation of dietary kitchen, the fryer was not clean, there were had food scraps on the baskets and fryer. Bottom shelf on prep table had , food crumbs on bottom shelf and containers lids of flour, sugar and powered milk lids covered with food crumbs. On 5/13/25 at 10:50am interview with the Dietary Manager, the Dietary Manager stated that the fryer was last used…

  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 before2025-05-15 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (LVN A) of three staff reviewed for infection control practices. LVN A did not perform any hand hygiene before or after medication administration for Resident #26, Resident #4, or Resident #8. LVN A did not sanitize reusable electronic wrist blood pressure cuff before or after use during medication administration for Resident #4 or Resident #8. These failures could place residents at risk of the spread of infections. Findings included: During an observation on 05/14/25 at 07:09 AM, LVN A prepared Resident #26's medication without performing any hand hygiene beforehand. LVN A provided Resident #26 with their medication and the resident had a bit of a coughing spell. LVN A provided the resident with additional water and watched resident until she was fine. LVN A then left room, went back to 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-07 · tag F0607 — failed to have anti-abuse policies — pattern
  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

  Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse and neglect for 3 of 7 staff (LVN #1, [NAME] #2,CNA #3, and CNA #4) reviewed for background screenings. The facility failed to ensure that employees were screened for a history of abuse, neglect, exploitation, or misappropriation prior to employment for LVN #1, Cook# 2, and CNA #3, and CNA # 4. Criminal history checks, and checks of the EMR/NAR were not conducted prior to employment. These deficient practices could place residents at risk for abuse and neglect. The findings were: 1.Review of the personnel file for LVN #1 indicated a hire date of 07/2/2024 and the Criminal History background check was verified on 12/3/24, and initial EMR/ NAR verified on 3/4/25. 2. Review of the personnel file for [NAME] # 2 indicated a hire date of 12/02/2024 and the Criminal History background check was verified on 01/13/2025, and initial EMR/NAR verified on 01/21/2025. 3. Review of the personnel file for the CNA # 3 indicated a hire date of 06/28/2024 and 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-07 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident # 4) of 6 residents reviewed for infection control, in that: The facility failed to implement Enhanced Barrier Precautions for Resident #4 who required feedings via a gastrostomy tube (a surgically created hole with a tube inserted into the stomach to provide an alternative route for nutrition and hydration for the resident). This failure could affect residents and place them at risk for cross contamination and infections. The findings included: Record review of Resident #4's electronic face sheet dated 03/05/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Dysphagia (difficulty swallowing), Dementia, and Multiple sclerosis (a disease that affect the nervous system that leads 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-03-07 · 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 ensure drugs, biologicals and medical supplies used in the facility were stored and labeled in accordance with currently accepted professional principles, for 3 of 3 medication storage areas (medication room, Short Hall Cart, and Long Hall Cart ) reviewed for medication storage. The facility failed to ensure that all medications and supplies stored in the medication room the short hall Medication Cart were properly labeled and not past their expiration date. The Change-of-Shift Record of Control Substance Log for the Short Hall Medication Cart, and the Long Hall medication carts were missing signatures. These failures could place resident's at risk of ineffective therapeutic response to medications and a decline in health. The findings included: Record review of Resident #12's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: diabetes (high blood sugar). Record review of…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-03-07 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed kitchen sanitization. 1. The facility failed to ensure the floors were not soiled with food particles beneath the appliances and stainless-steel shelf units throughout the kitchen and dry storage area. 2. The facility failed to ensure two of two refrigerators did not have what appeared to be dried liquids, and food crumbs on the bottom floor of the refrigerator. These failures could place residents at risk for foodborne illness and a decline in health status. The findings included: Observations on 03/05/2024 at 9:40 AM, during the initial tour of the facility kitchen, revealed the following: - the floor was soiled with food debris and grease beneath shelves and appliances throughout the kitchen. - 2 of 2 refrigerators had what appeared to be spilled milk, dried liquids, and food crumbs on the bottom shelf. Observations on 03/05/2024 at 9:50 AM revealed daily cleaning logs,…

  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

“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

$149,221 in federal fines across 1 penalty.

• $149,221 — penalty dated 2025-09-19

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

CMS files one row per role, so the 17 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

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