Regency Village

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.

40.8% 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 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 50.0% 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 24 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 122 beds and averages 65.8 residents a day — about 54% occupied, or roughly 56 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 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.550 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 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 3.01 hrs/resident/day on weekends vs 3.46 on weekdays — 13% thinner on weekends. RN hours go from 0.56 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 69% 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 more than at the previous inspection — worsening. 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.

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

• Immediate jeopardy · Jdisputed · IDR2025-04-19 · 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 observation, interviews, and record reviews the facility failed to immediately inform the resident's physician of a significant change in a resident's physical condition for one of five residents (Resident #1) reviewed for notification of change. -The facility failed to ensure Resident #1 received podiatry services on 3/29/24 and failed to ensure staff accurately and thoroughly reported Resident #1's change in condition to his third toe on his right foot, to his physician on 04/01/24. NP A was asked by Resident #1 to assess his right foot when he reported pain on 04/04/24. Resident #1 was sent to the hospital on [DATE] and had the third toe of his right foot amputated on 04/07/24 and the remaining toes on his right foot amputated on 5/12/24. Resident #1 no longer walked independently and used a wheelchair for mobility since 4/7/24. His right foot remained unhealed on 04/10/25 and he continued to receive n-going wound care and treatments related to repeated infections and other complications. An IJ was…

  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
• Immediate jeopardy · Jdisputed · IDR2025-04-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one of five residents (Resident #1), reviewed for Quality of Care. -The facility failed to ensure Resident #1 received podiatry services on 3/29/24 and failed to ensure staff accurately and thoroughly reported Resident #1's change in condition to his third toe on his right foot, to his physician on 04/01/24. NP A was asked by Resident #1 to assess his right foot when he reported pain on 04/04/24. Resident #1 was sent to the hospital on [DATE] and had the third toe of his right foot amputated on 04/07/24 and the remaining toes on his right foot amputated on 5/12/24. Resident #1 no longer walked independently and used a wheelchair for mobility since 4/7/24. His right foot remained unhealed on 04/10/25 and he continued to receive n-going wound care and treatments related to repeated infections and other complications. An IJ was…

  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 · Jdisputed · IDR2025-04-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident # 2) reviewed for adequate supervision. --The facility failed to provide adequate supervision and put measures in place to prevent residents from eloping. Resident #2 had a history of exit seeking behaviors and wandering and eloped from the facility on 3/15/25. He was found walking on the street in front of the facility. The resident discharged to home 3/21/25. This noncompliance was identified as Past Non-Compliance. The IJ began on 3/15/25 and ended on 3/15/25. The facility corrected the noncompliance by conducting elopement assessments, updating care plans, providing in-servicing to staff, elopement drills, and ensuring all door locks were operating securely prior to surveyor entrance. This failure placed residents at risk 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.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2024-03-02 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident was free from abuse, neglect, and exploitation for 1 of 6 residents (Resident #27) reviewed for abuse and neglect. The facility failed to prevent and correct alleged violation of abuse regarding Resident #27 that was reported on 2/21/2024. It was alleged that on 2/20/2024 a charge nurse witnessed Resident #27's family member shaking the resident hard by her shoulders and was screaming at her. Resident #27 family member was instructed to leave the facility. The facility did not put in place a care plan or interventions to prevent the abuse from occurring again. The facility failed to thoroughly investigate the abuse allegation and mitigate further harm while they continue to investigate. This failure could place the census of 74 residents at risk of not having allegations of abuse or neglect investigated. These findings included: Record review of Resident #27's face sheet revealed she was a [AGE] year-old woman,…

  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 · G2024-03-02 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for 1 of 6 residents (Resident #27) reviewed for abuse and neglect. The facility failed to prevent and correct alleged violation of abuse regarding Resident #27 that was reported on 2/21/2024. It was alleged that abused occurred on 2/20/2024 when a charge nurse witnessed Resident #27's family member shaking her hard by her shoulders and was screaming at her. Resident #27 was heard saying that resident #27 yelled saying her family member was trying to kill her. Resident #27 family member was instructed to leave the facility. The facility did not put in place a care plan or interventions to prevent the abuse from occurring again. After the abuse, the family member went to Resident #27's doctor appointment on 2/27/24 and told the provider to continue providing care even though the resident was screaming and saying no. LVN B 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-15 · 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 interviews and record review, the facility failed to report and investigate an incident for 1 resident of 5 residents (Resident #1) reviewed for abuse/neglect in that: The facility failed to report an allegation of staff abuse made by Resident #1 of an incident that occurred on 11/8/25 at an unknown time, to the State Agency. This failure could place residents at risk of abuse of residents.Record review of the admission record dated 1/12/26, revealed that Resident #1 was a [AGE] year-old male who was originally admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included Amyotrophic Lateral Sclerosis (also known as ALS, is a nervous system disease that affects nerve cells in the brain and spinal cord. ALS causes loss of muscle control. The disease gets worse over time), muscle wasting atrophy on the right lower leg (the presence of both low muscle mass and low muscle function (strength or performance), and need for assistance with personal care (anything that a client needs 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-01 · 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 interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #1) of 5 residents reviewed for dignity.LVN S failed to change and/or irrigate Resident #1's foley catheter on 11/28/25 when it was leaking, not flowing correctly, and there was an order to change it and irrigate it PRN, causing Resident #1 to sit in urine soaked bed linen and t-shirt.This failure could place residents at risk for embarrassment, decrease in dignity, and a decrease in quality of life.Findings included:Record review of Resident #1's undated face sheet revealed he was a [AGE] year old male originally admitted on [DATE], with diagnoses of neuromuscular dysfunction of the bladder (unable to control bladder), paraplegia (paralysis of lower half), osteomyelitis of thoracolumbar vertebra (infection of the vertebra in the mid back area), Type 2 diabetes…

  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 · D2025-12-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a resident who entered the facility with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #1) of 5 residents reviewed for catheters.LVN S failed to change and/or irrigate Resident #1's foley catheter on 11/28/25 when it was leaking, not flowing correctly, and there was an order to change it and irrigate it PRN, causing Resident #1 to call 911 and go to the ER.This failure could place residents at risk of urinary tract infections, the bladder to burst, skin break down, embarrassment, and possible hospitalization.Findings included:Record review of Resident #1's undated face sheet revealed he was a [AGE] year old male originally admitted on [DATE], with diagnoses of neuromuscular dysfunction of the bladder (unable to control bladder), paraplegia (paralysis of lower half), osteomyelitis of thoracolumbar vertebra (infection of the vertebra in the mid back area), Type 2…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-20 · 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 the resident's right to be free from abuse for 1 of 7 residents (Resident #2) reviewed for abuse in that:The facility failed to ensure Resident #2 was free from abuse by Resident #1 on 07/25/2025 when Resident #1 hit Resident #2 in the face. This failure could place residents at risk of abuse and psychosocial harm. Findings included:Resident #1Record review of Resident #1's admission record, dated 11/20/2025, revealed a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included unspecified dementia (loss of memory), schizoaffective disorder, bipolar type (a mental illness that combines symptoms of schizophrenia [chronic mental disorder affecting thoughts, perceptions, emotions, and social interactions] and a mood disorder but does not meet the criteria for either alone), and personal history of traumatic brain injury (damage to the brain caused by a head injury). Record review…

  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 · Fcited before2025-05-14 · 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 food service safety in 1 of 1 kitchen reviewed for dietary services, in that: - The facility failed to keep kitchen equipment clean and free of grease build up. - The facility failed to label foods for identification and dated with expiration date. - The facility failed to ensure that expired food items and products were not stored in the walk- in refrigerator. These failures could place residents at risk for food-borne illness and/or transmission-based infections. Findings included: Kitchen observation and interview on 05/12/25 at 8:40am, revealed one of one commercial can opener had a dark looking substance around the cutting blades and the blade holder. The deep fryer had dark looking grease with white floating substances on top of the grease. [NAME] G said she was off for three days and today 05/12/25 was her first day back. She said the grease was usually changed once a week but not sure of when it was changed last.…

  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 · E2025-05-14 · tag F0641 — pattern
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that assessments accurately reflected residents' status for 3 (Resident #7, #16, #22) of 10 residents reviewed for accuracy of assessments. -The facility failed to ensure that Resident #7's falls that occurred on 4/20/25 were documented on their annual MDS assessment dated [DATE]. -The facility failed to ensure that Resident # 16 's falls were documented on her Annual MDS assessment dated [DATE], quarterly MDS dated [DATE] and 12/11/24. - The facility failed to ensure that Resident # 22 's falls were documented on her Annual MDS assessment dated [DATE], quarterly MDS dated [DATE] and 12/23/24. These failures could place residents at risk of receiving inadequate care and services based on inaccurate assessments. Findings included: Resident #7 Record review of Resident #7's face sheet dated 5/13/2025, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Acute on Chronic Systolic (Congestive)…

  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 before2025-05-14 · 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 observations, interviews and record reviews, the facility failed to develop and implement comprehensive care plans with measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs identified in the comprehensive assessment for of 20 residents reviewed for care plan accuracy(Residents # 59, 123, 17) ---there were no comprehensive care plans in Resident #'s 59, 123, and 17 elctronic medical records. These failures placed residents at risk of receiving inadequate care due to incomplete care plans. Findings include: Resident # 59 Record review of Resident # 59's face sheet revealed admission date 1/23/25 with diagnoses including Chronic Obstructive Pulmonary Disease (lung conditions causing airflow obstruction), hypertension (high blood pressure), heart failure (inability of heart to pump blood as it should), muscle weakness, lack of coordination (problems with balance). Record review of Resident # 59's admission MDS dated [DATE] revealed a BIMS score of 12,…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-14 · tag F0636 — isolated
  Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
  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 electronically transmit encoded, accurate, and complete MDS data to the CMS System, within 14 days, upon a resident's transfer, reentry, discharge, and death, for 1 of 18 residents (Resident #35) reviewed for transmitted MDS data to the CMS System. The facility failed to complete Resident #35's admission MDS assessment within 14 days of admission. This failure could place residents at risk of not having their assessments transmitted timely which could cause a delay in treatment. The findings included: Record review of Resident #35's face sheet dated 05/13/25 revealed a -[AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #35's admission MDS assessment, dated 12/18/2024, revealed the signature page indicated it was signed as completed on 12/30/24, 18 days after admission. During an interview with the DON on 5/13//25 at 2:00pm the DON said the MDS staff signed a few days ago. She said the MDS were being done remotely 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  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 residents who were unable to carry out Activities of Daily Living received the necessary services to maintain grooming and personal hygiene for 1 (Resident #7) of 5 residents reviewed for Activities of Daily Living. The facility failed to provide Resident #7 with adequate oral care. This failure could place residents at risk of diminished quality of life or decreased self-esteem. Findings included: Record review of Resident #7's face sheet dated 5/13/2025, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Need for Assistance with Personal Care. Record review of Resident #7's annual MDS dated [DATE] revealed a BIMS score of 00 that indicated severe cognitive impairment. Record review also revealed score of 03 which was partial/moderate assistance for oral hygiene in Section GG0130. Record review of Resident #7's care plan printed 5/13/25 revealed the resident required extensive…

  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 · D2025-05-14 · 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 observation, interview and record review, the facility failed to ensure that residents who needed respiratory care was provided such care, consistent with professional standards of practice for 2 (Residents #27 and #32) of 4 residents reviewed for respiratory care. The facility failed to ensure Resident #27's oxygen humidifier was not empty and Resident #32's oxygen concentrator was working appropriately by not beeping. The failure could place residents at risk of developing respiratory complications or having decreased quality of care from dry nasal passages that could lead to nosebleeds or sores. Findings included: Resident #27 Record review of Resident #27's face sheet dated 5/13/2025, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (progressive brain disorder that destroys memory and thinking skills) and Heart Failure (disorder when the heart does not pump blood as well as it should). Record review of Resident #27'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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Fines & penalties

$22,718 in federal fines across 2 penalties.

• $8,417 — penalty dated 2025-04-19
• $14,301 — penalty dated 2025-04-19

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 CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 12 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 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