Paradigm at the Creek

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.

Therapy staffing: this home’s payroll records show 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.

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

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

Staffing

How full it usually is: this home is certified for 120 beds and averages 56.0 residents a day — about 47% occupied, or roughly 64 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 3.23 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 2.75 hrs/resident/day on weekends vs 3.42 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.40 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 59% 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.

44 citations, most serious first. The 17 most serious are shown; the remaining 27 are one tap away and print in full.

• Immediate jeopardy · Kcited before2025-08-04 · 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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (CR#1) of 6 residents reviewed for comprehensive care in that:-The facility failed to ensure CR#1's care plan interventions had not been updated since 2024 despite recent falls including falls with injury. CR#1 had unwitnessed falls on 07/08/25 and another on 07/10/25. CR#1 was transported to the hospital where she was diagnosed with rib fractures and had a chest tube placed.An Immediate Jeopardy (IJ) situation was identified on 8/1/2025 at 3:30pm. While the IJ was removed on 8/4/2025 at 6:45pm, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These…

  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
• Immediate jeopardy · Jcited before2024-09-30 · 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 each residents had the right to be free of abuse for 2 of 9 residents (Resident #2 and Resident #3) reviewed for resident-to-resident abuse. The facility failed to ensure Resident #2 was free from abuse when CR#1 banged Resident #2's head on the floor causing a laceration to the back of his head and requiring 32 staples. The facility failure to ensure residents were free from abuse due to Resident #3 and Resident #4 having an altercation resulting in Resident #3 sustaining a cut to the chin by Resident #4. An Immediate Jeopardy (IJ) was identified on 09/27/2024 at 4:24pm. While the IJ was removed on 09/30/2024 at 2:22pm, the facility remained out of compliance at a scope of Level 2 (E) Although there was IJ for two persons, the potential for more than minimal harm is isolated, the facility continued to monitor the implementation and effectiveness of their corrective systems. These failures could place residents who are dependent 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-09-30 · tag F0725 — failed to have enough nursing staff — isolated
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  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 have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility's assessment tool for 2 of 19 residents (Resident #2 and Resident #3)reviewed for sufficient staff. -The facility failed to ensure adequate supervision was provided for Resident #3's wandering to prevent resident-to resident altercations between Residents #3 and #4 on 8/10/24 and 9/2/2024 in which Resident #3 sustained injuries to his face. -The facility failed to ensure there was sufficient staff on the secured unit overnight shift (10pm-6am) on 9/22/2024 to prevent a resident-to-resident altercation…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-05-28 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  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 personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 of 19 residents (CR #1) reviewed for CPR. 1. Laundry Aide D failed to call a code blue or express CR #1 experienced a medical emergency when she requested assistance in the locked memory care unit after CR #1 was noted to be unresponsive on 05/18/2024. This led to a delay of at least three minutes before nursing staff arrived to assess CR #1, who died shortly after arrival to the ER. 2. CNA A initiated CPR with improper chest compressions prior to knowing if CR #1 was full code and prior to checking for a pulse while he was still sitting unresponsive in his wheelchair on 05/18/2024. 3. Staff failed to immediately retrieve and ensure the crash cart and AED were unlocked and readily accessible after CR #1 was noted to be unresponsive. This led to a delay of approximately 3-5…

  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
• Actual harm · Gcited before2026-05-22 · 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 each resident was free from abuse for 1 of 16 residents (Resident #1) reviewed for abuse. Resident #2 was physically abusive to Resident #1 on 3/5/26 when he punched her with a closed fist in the head after which Resident #1 was observed crying and upset. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 3/5/26 and ended on 3/6/26. The facility corrected the noncompliance before the survey began. These failures placed residents, who resided in the facility, at risk of abuse, pain and emotional distress. The findings included: Resident #1 Record review of Resident #1's admission Record generated on 5/22/26 revealed she was admitted to the facility on [DATE] and had diagnoses of dementia (an umbrella term for a decline in mental ability-such as memory, thinking, and reasoning-severe enough to interfere with daily life), schizophrenia (a chronic brain disorder that disrupts how a person…

  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
• Actual harm · Gcited before2025-05-16 · 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, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent and accidents for one (Resident # 1) of 5 residents reviewed for supervision. The facility failed to provide adequate supervision to Resident # 1 to prevent injury of unknown origin (a physical injury where the cause or source is not known, or could not be explained, and raises suspicion of abuse or neglect due to the injury's size, location, or circumstances) which resulted in Resident # 1, who is totally dependent on staff for care, having a mildly displaced fracture of the fourth proximal phalanx (the bone closest to the base of a finger) on 5/7/2025 when a family member visited and noted a swollen finger. Resident # 1 did not leave the facility on an outing and only facility staff provided care to Resident # 1. This deficient practice has the potential to affect all residents in the building by causing resident injuries, such as fractures, falls, and even death due 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-05-08 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 residents (Resident #1) of 6 reviewed for pain management in that: -The facility failed to address Resident #1's pain in her left leg and ankle after falls on 1/31/24, 2/8/24 and 4/2/24 and unresolved pain relief from the Tylenol and Tramadol prescribed. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life. Findings included: Resident #1 Record review of Resident #1's face sheet dated 5/2/2024 revealed she was a [AGE] year old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of critical illness myopathy(generalized weakness involving the muscles of the extremities, trunk, and respiration), chronic obstructive pulmonary…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-07-01 · 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 observation, interview and record review the facility failed 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 are identified in the comprehensive assessment for 1 of 6 residents (CR #1) reviewed for comprehensive care plans. The facility failed to develop a care plan area for CR #1's hyperammonemia. The facility failed to implement CR #1's care plan interventions related to medication management and behaviors by not administering prescribed routine dosage of lactulose from 5/4/2026 - 5/23/2026 resulting in approximately 57 missed doses. These failures could place residents at risk for unmanaged medical conditions, worsening mental status and behaviors, and a decline in physical and psychosocial well-being. Findings included: Record review of CR #1's facesheet revealed a [AGE] year-old male admitted 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 no plan of correction
• Potential for harm · E2026-07-01 · tag F0760 — failed to prevent significant medication errors — pattern
  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 interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 6 residents (CR #1) reviewed for medication errors. The facility failed to provide CR #1 with lactulose 30mg three times a day to manage ammonia levels from 5/4/2026 - 5/23/2026 resulting in approximately 57 missed doses. This failure placed residents at risk for elevated ammonia levels which could seriously impair him or cause increased behaviors. Findings include: Record review of CR #1's face sheet revealed a [AGE] year-old male admitted on [DATE] and discharged to the hospital on 5/23/2026. His diagnoses included: Alzheimer's Disease (progressive, irreversible brain disorder that slowly destroys memory and thinking skills), Major Depressive Disorder (mental health condition that affects a person's mood, thoughts, and ability to participate in normal activities), and Disorder of Urea Cycle Metabolism (condition in which the body cannot properly remove waste ammonia from the…

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

  Pharmacy Service Deficiencies · Deficient, Provider has no plan of correction
• Potential for harm · Ddisputed · IDR2026-07-01 · 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 interview and review the facility failed to report alleged violations of abuse, neglect, exploitation of mistreatment, including injuries of unknown source. Immediately but no later than two hours if the events that cause the allegation involve abuse or result in serios bodily injury for 1 out of 1 incident (Resident # 1) sampled for abuse and neglect.The facility failed to report an unwitnessed fall of Resident # 1 that resulted in a fracture of clavicle.This failure places residents at risk of not receiving complete or accurate investigation of incidents that resulted in emergency services implementing interventions.Findings includedRecord review of Resident # 1 face sheet revealed an [AGE] year-old male with readmission date of 5/24/2026. Diagnoses include pain, age-related osteoporosis (a condition where bones become weak, brittle, and porous due to a decrease in bone mass and density), cellulitis (a common, potentially serious bacterial skin infection) of the lower right limb, acute hematogenous…

  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 no plan of correction
• Potential for harm · Dcited beforedisputed · IDR2026-07-01 · tag F0641 — isolated
  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 conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 out of 4 (Resident #1) residents reviewed for resident assessmentsThe facility failed to revise Resident # 1 MDS to address cellulites (a common, potentially serious bacterial skin infection)of right lateral foot and right ankle and the intervention of antibiotics. This failure causes a risk to residents not receiving current or updated treatment and monitoring of infections based on MDS triggered Care Plans Area.Findings includeRecord review of Resident # 1 face sheet dated 6/16/2026 revealed an [AGE] year-old male with an original admission date of 8/27/2021readmission date of 5/24/2026. Diagnoses included pain, age-related osteoporosis (a condition where bones become weak, brittle, and porous due to a decrease in bone mass and density), cellulitis (a common, potentially serious bacterial skin infection) 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has no plan of correction
• Potential for harm · E2026-05-22 · tag F0610 — failed to investigate and act on abuse reports — pattern
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record reviews, the facility failed to have evidence that the alleged violation was thoroughly investigated in response to allegations of abuse or neglect for 7 of 16 residents reviewed for freedom from abuse and neglect (Residents #1, #4, #5, #6, #7, #9, and #11). The Administrator failed to have evidence that an alleged violation of an injury of unknown origin was thoroughly investigated and included witness statements from staff members when Resident #4 was found to have a fractured toe on 2/26/26. The Administrator failed to have evidence that an alleged violation of abuse was thoroughly investigated and included witness statements from staff members when Resident #1 was hit in the head by Resident #2 on 3/5/26. The Administrator failed to have evidence that an alleged violation of abuse was thoroughly investigated and included witness statements from staff members when there was an allegation that Resident #5 and Resident #6 kicked each other and Resident #6 spilled coffee on Resident #5 on 3/22/26. The Administrator failed to have evidence that an…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-06 · 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, interview, and record review the facility failed to ensure each resident's environment remained free of accident hazards for 1 of 6 residents (Resident #2) reviewed for accident hazards.The facility failed to ensure Resident #2 had an adequate assistance device in that his wheelchair brake was inoperable, resulting in a fall on 3/10/26. Resident #2 had been using the wheelchair between 3/10/26 and 5/6/26. This failure could place residents at risk for falls, pain and injuries. Findings included:Record review of Resident #2's admission Record generated on 5/6/26 revealed he was admitted to the facility on [DATE] with diagnosis of osteomyelitis (serious infection of the bone, causing inflammation and pain, often triggered by bacteria or fungi. He was [AGE] years old. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed he had a BIMS of 12, indicating he had moderate cognitive impairment. He used a wheelchair for mobility and required substantial/maximal assistance 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-05-23 · 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 observations, interviews, 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 food procurement. 1. The facility failed when Dietary Aide A and Dietary Aide B did not don (put on) hair nets while preparing breakfast in the facility kitchen on 05/20/2025. These failures could place residents at risk of food borne illness and disease. Findings included: During an observation and interview on 5/20/25 at 8:10 AM, Dietary Aide A was observed preparing breakfast prior to donning (putting on) a hair net. Dietary A went and donned a hair net. Dietary Aide A was interviewed and asked why it is important to wear a hair net and she replied, so they (unknown) will not tell the Administrator. An observation and interview on 5/20/25 at 8:15 AM of Dietary Aide B who was working in the kitchen without donning a hair net. Dietary Aide B said she was sorry while donning her hair net at the same time, she said it was important to wear a hair net while in the kitchen…

  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 · E2025-05-23 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 1 of 3 showers (shower room on Hall A) reviewed for resident rights. 1. The facility failed to ensure the shower room floor did not have black marks with debris on floor. 2. The facility failed to ensure resident personal care items were labeled. 3. The facility failed to ensure 2 full sharp containers were not filled with razors, 2 wheelchair footrests were not on the floor, linen was not laying on the seat of a wheelchair, and a pair of rainboots were not under one wheelchair. These failures could place residents at risk for injuries, cross contamination, unwanted infections, and a decrease in quality of life. Findings include: Observation on 05/20/25 at 12:00 PM on Hall A in the shower room revealed the following: A shower chair in the left corner of the room was a scrub brush laying on the floor, a pair of rain boots on the floor…

  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 before2025-05-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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 based on the comprehensive assessment of a resident, the facility ensured a resident with pressure ulcer received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent new pressure ulcers from developing for 1 of 8 residents (Resident #3) reviewed for pressure ulcers, 1. The facility did not have Dakins solution (diluted bleach used to clean wounds) available for Resident #3's wounds to right and left ischial (a bone you sit on that fuse to form the hip bone), and sacrum (a large, triangular-shaped bone located at the base of the spine). 2. The Wound Care Nurse did not clean Resident #3's wound to prevent introducing bacteria into the wound bed. 3. The facility failed to ensure the Wound Care Nurse did not take her laptop with mouse in Resident #3's room when providing wound care on 05/21/25. These failures could place residents at risk for unwanted…

  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 · E2025-05-23 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission and communicable disease and infections for 2 (Resident #49 and Resident #117) of 8 residents whose care was reviewed for infection control in that: 1. The facility failed to have Infection Control Signage regarding EBP on 05/20/2025 for Resident #49 who had a surgical wound to his right great toe . 2. Resident #117's urinary catheter tubing was observed touching the floor on 05/20/2025 and 05/21/2025. This failure placed residents at risk for infections and decrease in quality of life. Findings included: 1. Record review of Resident #49's face sheet dated 05/22/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and again on 05/11/25. Resident diagnoses included the following: heart disease, hypertension (high blood pressure), 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.

  Infection Control 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

$52,034 in federal fines across 4 penalties.

• $8,191 — penalty dated 2025-08-04
• $8,402 — penalty dated 2025-05-16
• $20,719 — penalty dated 2024-09-30
• $14,722 — penalty dated 2024-05-08

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 PARADIGM HEALTHCARE — 17 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 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

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.

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