Deer Creek Nursing and Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

49.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 46.0% 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 37 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 0.72 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% 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 70.3 residents a day — about 58% occupied, or roughly 52 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 2.69 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.59 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 2.34 hrs/resident/day on weekends vs 2.83 on weekdays — 17% thinner on weekends. RN hours go from 0.61 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

35 citations, most serious first. The 16 most serious are shown; the remaining 19 are one tap away and print in full.

• Immediate jeopardy · Kcited before2025-08-01 · tag F0580 — failed to tell family and doctor about changes — pattern
  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 consult with the resident's physician when there was a significant change for one (Resident #1) of four residents reviewed for notification of changes. The facility failed to notify the NP when Resident #1's diabetic pump malfunctioned in July of 2025. Resident #1's blood sugar readings were sporadically out of range which led her to experience increased dizziness, nausea, and sweatiness. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/25 PM and a template was provided. While the IJ was removed on 08/01/25 at 2:13 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of DKA, dizziness, nausea, and a decreased quality of life. Findings included:Review of Resident #1's undated face sheet reflected a [AGE] year-old female who 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 · Kcited before2025-08-01 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care. The facility failed to: - Notify Resident #1's NP when her diabetic insulin pump malfunctioned in July of 2025. - Ensure nursing staff were trained on Resident #1's insulin pump.- Ensure nursing staff were aware of how much insulin Resident #1 was receiving and not relying on her for blood sugar readings.- Ensure there were parameters in place on when to notify Resident #1's NP when her readings were abnormal.These failures resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/25 at 2:14 PM and a template was provided. While the IJ was removed on 08/01/25 at 2:13 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-05-05 · 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, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change for one (Resident #1) of four residents reviewed for notification of changes. The facility failed to ensure the NP was notified on 02/10/25 when there was reported swelling and tenderness to Resident #1's incision sites. On 02/11/25 one of the incisions dehisced requiring hospitalization where he was diagnosed with an infection to the surgical site requiring antibiotics. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/02/25 at 4:44 PM. While the IJ was removed on 05/05/25 12:46 PM, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary medical care, pain, infection, and hospitalization. Findings included: 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-05-05 · 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, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care. The facility failed to ensure Resident #1's surgical sites were determined to be healed by the NP or MD. On 02/10/25 there was reported swelling to the incisions and on 02/11/25 one of the incisions dehisced requiring hospitalization where he was diagnosed with an infection to the surgical site requiring antibiotics. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/02/25 at 4:44 PM. While the IJ was removed on 05/05/25 12:46 PM, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not…

  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 before2025-09-29 · 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 records review the facility failed to ensure that residents (Resident #1) environment remains as free of accident hazards. The facility failed to ensure Resident #1 was free of accidents and hazards, as Resident #1 spilled a hot liquid onto her leg. Resident #1 sustained a second-degree burn to her left thigh. This failure placed residents at risk of serious harm and injuries which could result in hospitalization and a diminished quality of life. Findings included: Observations on 9/26/2025, at 10:00 a.m. revealed no hot water dispensers were observed in the halls of the facility. Observation and interview on 09/26/2025, at 12:25 p.m. revealed Resident# 1 was observed lying in bed and watching TV. Resident#1 stated she expressed that she is doing well overall. While she did mention having a burn on her leg, she said she was not in pain, and that she felt safe in the facility. Resident #1 mentioned that she was aware that the water dispenser provided hot water and had used it…

  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 · G2023-09-27 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents had the right to be free from neglect for one (Resident #1) out of three residents reviewed for neglect, in that: The facility failed to ensure Resident #1's environment was safe and comfortable when she was left alone in a hot motorized van with the doors open for 14 minutes causing her to feel dizzy, thirsty, panicked, and the fearful she would lose consciousness. This failure placed residents at risk of experiencing helplessness, heat exhaustion, dehydration, and a decrease of self-worth. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including bradycardia (slow resting heart rate), syncope (fainting), and hypertension (high blood pressure). Review of Resident #1's quarterly MDS assessment, dated 09/18/23, reflected a BIMS of 15, indicating she was cognitively intact. 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
• Potential for harm · Dcited before2025-12-22 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for one (Resident #1) reviewed for medications.The facility failed to document the receipt and disposition Resident #1's Oxycodone HCI medication.This failure could result in controlled medications not accurately and periodically reconciled.Findings included:Record review of Resident #1's face sheet reflected a [AGE] year-old female with diagnoses which included chronic diastolic (congestive) heart failure, essential (primary) hypertension, and generalized muscle weakness. Resident #1 also had diagnoses for pain in both the right and left knees, along with other chronic pain issues, highlighting a potential need for effective pain management.A record review of Resident #1's medication administration record (MAR), dated 12/22/2025, reflected on 11/20/2025, Resident #1 was ordered Oxycodone HCl oral tablets, 5 mg, 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-12-01 · 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 for one of one kitchen reviewed for sanitation. The facility failed to ensure all items were covered and stored properly.The facility failed to label and date all food items in the kitchen.The facility failed to ensure all staff in the kitchen wore hairnets or beard guards. These failures could place residents at risk of foodborne illness.Findings included: An observation on 09/25/25 at 9:58 AM revealed a partially used 50-pound bag of refined sugar, open and undated, on a shelf in the storage room. An observation on 09/25/25 at 9:59 AM revealed a large bag of enriched flour, open and undated on a shelf in the storage room. An observation on 09/25/25 at 9:59 AM revealed a large plastic storage bin labeled Flour 07/22. The lid was not secure on the storage bin. An observation on 09/25/25 at 10:01 AM revealed a brownish-orange pudding like substance in a plastic container in the walk-in refrigerator. 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-01 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance for 1 of 1 meal (lunch) reviewed for pureed diet texture. The facility failed to ensure the nutritional content of the pureed food when the facility used water only to puree the chicken tenders and broccoli on 09/25/25. This deficient practice could place residents at-risk for poor intake and malnutrition related to decreased calorie intake.Findings included: An observation on 09/25/25 at 12:17 PM revealed the CK pureed about twelve chicken tenders and added water to the food processor. After several minutes, the CK evaluated the consistency of the puree, put more tap water into a pitcher, and poured the water into the food processor. After cleaning the processor, the CK repeated the process of using tap water to puree the broccoli. During an interview on 09/25/25 at 12:24 PM, the CK stated she did not have a recipe but knew the puree was supposed to look like pudding. She…

  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 · Fcited before2025-06-26 · 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 for one of one kitchen reviewed for sanitation. 1.The facility failed to ensure sanitation practices (cleaning the ice machine, cleaning the juice machine dispenser, cleaning the inside of the microwave, covering lemonade and iced tea drink receptacles to ensure they remain free of contamination, storing the ice scoop in an ice scoop receptacle that had a lid and that was free from standing water accumulation and free from food debris buildup, ensuring staff utilize hair restraints while in the kitchen, ensuring trash receptacles in the kitchen had lids secured covering contents, cleaning the walk in refrigerator unit shelving and walls to ensure they are free of mold and debris, sweeping the kitchen prep area floors to be free of debris and crumbs, and cleaning the kitchen prep area shelving to be free of debris and crumbs) 2.The facility failed to ensure cleaning logs were being completed. 3.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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-06-26 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 1 of 1 resident council reviewed. The facility failed to follow up on concerns and requests expressed in resident council meetings from January 2025 through June 2025. This failure placed residents at risk of not having their preferences honored. Findings included: Review of Resident Council minutes reflected the following with no documentation of the facility's responses to the grievances: February 2025 reflected: choose 5 entrees with sides and dietary manager will try to choose 3 he can possibly make for the future month. 1 meal can be chosen out of the 3 for a meal of the month. 3/6/2025 reflected: wanting to know when we can start meal of the month. 4/3/2025 reflected: 2. Resolutions from last month are not satisfactory or even resolutions. 3. Will start by taking ideas…

  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 · Edisputed · IDR2025-06-26 · tag F0567 — failed to protect residents' money held by the home — pattern
  Honor the resident's right to manage his or her financial affairs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and records review, the facility failed to allow residents to manage his or her financial affairs for 1 of 1 resident council reviewed. The facility failed to ensure all residents whose funds are managed by the facility had ready access to his or her funds upon request in a timely manner, including non-business days, Saturday, and Sundays. This failure could place all residents whose funds were managed by the facility of not receiving funds deposited with the facility and not having their rights and preferences honored. Findings included: During a Resident Council meeting on 6/25/2025 at 2:00 PM, 16 anonymous residents stated they were allowed to access their petty trust funds during the week. They all stated they were not aware of a petty cash fund policy, but they know it is accessible on the weekdays and to work with RECP to withdraw petty cash. They all stated they liked to get dollar bills for the vending machines. They all stated they were not able to access funds during the weekend as the RECP did not work those days. The VP and President both stated there…

  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 before2025-06-26 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed. 1.The pureed kitchen test tray of the lunch meal foods were unappealing and lacked flavor. The pureed kitchen test tray lacked condiments, the food items did not hold their form and ran together, there was no garnishment of the food tray, and the dessert of lemon pie parfait was so thick, gummy, and tasted of food thickener it was inedible. 2. The regular texture kitchen test tray of the lunch foods were unappealing and lacked flavor. The regular texture kitchen test tray lacked condiments, the food items of roast pork loin was dried out, Harvard beet juice had run into the rice pilaf, the dessert of lemon pie parfait was not a full serving size of ½ cup, and there was no garnishment of the food tray. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. Findings included:…

  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 · E2025-06-26 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
  Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure that residents had suitable, nourishing meals and snacks outside of scheduled meal service times for 2 of 2 halls (100 and 200 halls) and 2 of 2 refrigerators in 2 of 2 nourishment rooms (100 hall and 200 hall) reviewed for evening snack. The facility failed to ensure residents were offered snacks at bedtime on the 100 and 200 halls. The facility failed to have reserves of snacks for after dinner and at bedtime in 2 of 2 refrigerators in the nourishment rooms. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for unplanned weight loss, side effects from medication given without food, and diminished quality of life. Finding included: Observation on 6/24/2025 at 9:39 AM of hall 200 nourishment room revealed health shakes, cartons of milk, and containers of yogurt in refrigerator. One peanut butter and jelly sandwich on nourishment room shelf dated 6/23 and several packages of peanut butter crackers. Further observation revealed…

  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 · Edisputed · IDR2025-06-26 · tag F0919 — failed to provide a working call system — pattern
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  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 adequately equip residents the ability to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area, from the bathroom for 56 of 61 resident rooms reviewed for resident call systems. The facility failed to ensure resident bathrooms had a pull string attached to the push button call light switch making the call light button inaccessible if the resident was lying on the floor in their bathrooms in rooms: 1) 100 2) 102 3) 103 4) 105 5) 106 6) 107 7) 110 8) 111 9) 113 10) 115 11) 116 12) 117 13) 118 14) 119 15) 120 16) 121 17) 122 18) 123 19) 124 20) 125 21) 126 22) 127 23) 128 24) 129 25) 130 26) 131 27) 200 28) 201 29) 202 30) 203 31) 204 32) 205 33) 206 34) 207 35) 208 36) 209 37) 210 38) 211 39) 212 40) 213 41) 214 42) 215 43) 217 44) 219 45) 221 46) 222 47) 223 48) 224 49) 225 50) 226 51) 227 52) 228 53) 229 54) 230 55) 231 56) 232 This failure could…

  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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-26 · tag F0925 — failed to control pests — pattern
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  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 maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 facility reviewed for pests. 1. The facility failed to ensure resident rooms were free from flies for Resident #58. 2. The facility failed to ensure the facility was free of gnats and flies throughout the facility including dining rooms, hallways, and kitchen. This failure placed residents at risk of exposure to pests, diseases, infections, and diminished quality of life. The findings included: 1. Record review of Resident #58's admission record, dated 06/26/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #58 had diagnoses which included: chronic obstructive pulmonary disease (a chronic lung disease that limits airflow and causes ongoing respiratory symptoms), chronic kidney disease (a disease that impairs the kidney's ability to filter toxins), unspecified dementia (a disease that causes…

  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.

  Environmental 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

$75,581 in federal fines across 4 penalties.

• $12,438 — penalty dated 2025-09-29
• $17,131 — penalty dated 2025-07-23
• $20,482 — penalty dated 2025-05-05
• $25,530 — penalty dated 2023-09-27

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 EDURO HEALTHCARE — 34 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 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.

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.

About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX