Windcrest 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.

50.0% 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 78 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 180 beds and averages 73.0 residents a day — about 41% occupied, or roughly 107 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 2.90 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.22 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.67 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.71 hrs/resident/day on weekends vs 2.97 on weekdays — 9% thinner on weekends. RN hours go from 0.23 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%.

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.

38 citations, most serious first. The 15 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-07-31 · 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

  Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #3) reviewed for quality of care. Resident #3 exited the facility through an alarming secure unit exit door on 5/14/2025. CNA A turned off the alarm without looking for Resident #3. Resident #3 left the facility and went missing for over 1.75 hours. The police found Resident #3 in a parking lot near an interstate highway and highway access roads. The noncompliance was identified as PNC. The IJ began on 5/14/2025 and ended on 6/4/25. The facility had corrected the noncompliance before this investigation survey began. This failure could place residents at risk of injury or death due to lack of supervision. The findings were: Record review of Resident #3's face sheet, dated 7.29.25, and EMR (electronic medical record) revealed the resident was admitted on 4.18.25 with diagnoses that included: ALZHEIMER'S DISEASE WITH LATE ONSET, insomnia, dementia, depression, and anxiety. The RP (responsible party) was a…

  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
• Immediate jeopardy · Jcited before2025-03-03 · 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, interviews and record reviews, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 of 6 residents (Resident #2) reviewed for abuse, in that: The facility did not properly monitor or put in place preventative measures for Resident #2, who had a severe cognitive impairment, to prevent an act of sexual abuse by Resident #1 on 02/13/25, when he kissed Resident #2, and 02/14/25, when he fondled Resident #2. An IJ was identified on 02/27/25. The IJ template was provided to the facility on [DATE] at 06:18 PM. While the IJ was removed on 03/01/25 at 05:00 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm. This failure could result in residents suffering injury, a diminished quality of life, and psychosocial harm. The findings were: Record review of Resident #1's admission Record reflected he was a [AGE] year-old male initially…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-03-03 · 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 interviews, and record reviews the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 8 Residents (Resident #4) reviewed for neurological assessments after a fall. 1. On [DATE] at approximately 5:28 AM Resident #4 had an unwitnessed fall and was discovered on the floor in her bedroom, and LVN H failed to perform neurological assessments for Resident #4 at 6:45 AM, and at 7:15 AM, and failed to report to LVN I she had not assessed Resident #4 and at 8:00 AM Resident #4 and discovered deceased . 2. On [DATE] at approximately 7:40 AM LVN I assessed Resident #4 without performing a neurological assessment at 7:45 AM and did not document Resident #4's vital signs. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began on [DATE]. These failures could place residents at risk for harm by lack of interventions up and including death. The findings included: A…

  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
• Immediate jeopardy · Jcited before2024-05-30 · 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 interviews and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 21 residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA B reported when HA A allegedly abused Resident #1 on [DATE]. The facility failed to ensure HA A was not working after this alleged abuse and had access to residents for her overnight shift. The facility failed to ensure all staff members were properly educated on abuse, neglect, and exploitation after this incident. On [DATE] at 03:52 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed prior to exit on [DATE], the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-05-30 · 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 observations, interviews, and record reviews 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 1 of 6 (Resident #3) reviewed for quality of care. Resident #3 had signs and symptoms of a stroke and was not sent to the hospital for evaluation for approximately 6 hours after a change of condition was reported. The non-compliance was identified as past non-compliance. The immediate jeopardy began on 2/23/2024 and ended on 2/28/2024. The facility corrected the non-compliance before the investigation began. This deficient practice placed all residents at risk of experiencing a delay in treatment that could have resulted in harm or potentially death. The findings included: Record review of the admission record revealed Resident #3 was a [AGE] year-old male, originally admitted on [DATE]. Diagnosis information revealed positive for gastrostomy status with 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.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · F2025-08-14 · 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

  Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to label the name of food products (ice cream) in the food preparation refrigerator. 2. The facility failed to label dates on cheese and butter in the food preparation refrigerator. 3. In the walk-in refrigerator, the facility failed to keep food products 12 inches away from the ceiling and there was not a discard date on a pack of tortillas. These failures could place residents at risk for food borne illness. The findings included: 1. Interview and observation, during the initial kitchen tour, on 08/12/25 at 09:43AM, in the food preparation area freezer, there were containers of ice cream for lunch that were not labeled ice cream, but there was a label for the date 08/12/25. The CDM revealed sometimes they put labels of the names of the food products and sometimes they don't. (There was no reason given…

  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 before2025-08-14 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for 3 of 8 residents (Residents #28, #69, and #76) reviewed for ADLs in that:The facility failed to ensure Resident #76 received consistent showers during August and July 2025. The facility failed to ensure Resident #28 was provided with appropriate feeding assistance for 08/14/25 lunch meal.The facility failed to help Resident #69 with eating on 08/14/25 lunch meal per his care plan.These failures could place residents at risk of not receiving care and services to meet their needs, including nutritional needs and/or a diminished quality of life. Findings included: 1. Record review of Resident #76's face sheet, dated 8/12/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Parkinson's Disease (a progressive neuromuscular…

  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 · E2025-08-14 · tag F0727 — failed to provide required RN coverage — pattern
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record reviews and interviews the facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 1 of 1 facility's reviewed for nursing staffing.The facility failed to have the services of an RN (Registered Nurse) 04/13/2025, 04/19/2025, 04/27/2025, 05/04/2025, 05/10/2025, and 05/11/2025. This failure could place residents at risk of not having the critical skills of a RN.Findings included:A record review of the facility's RN staff payroll hours for the period of 1/1/2025 - 8/14/2-25 revealed no RN Services on the following dates: 04/13/25, 04/19/25, 04/27/25, 05/04/25, 05/10/25, and 05/11/25. Record review of Incidents & Accidents for April 2025 and May 2025 did not reveal any negative outcomes to residents related to not having RN services.In an interview on 8/14/25 with the Administrator, the Administrator stated she was not aware there was no RN coverage on those dates. Administrator stated the former Director of Nurses was available on-call as needed. The Administrator stated she was aware of the importance…

  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
• Potential for harm · E2025-08-14 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles; included the appropriate accessory and cautionary instructions and the expiration date when applicable; and under proper temperature control for 2 of 3 medication aide carts (B and C hall carts) reviewed for medication storage. The facility failed to ensure 3 vials of the medication Latanoprost, including one with no open date, were discarded within 6 weeks (42 days) of removal from refrigeration.These failures could lead to residents receiving ineffective medications and not receiving the intended therapeutic effect. Findings included:In an observation and interview on 8/13/2025 at 8:46 AM, one vial of Latanoprost was observed in the B hall cart with an opened date of 6/28/2025 (56 days). MA L stated she was unsure when the medication was supposed to be discarded after being removed from refrigeration. In an observation and interview on 8/13/2025 at 8:55 AM, one vial of…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-14 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 CNAs (CNAs M, N, and O) observed for infection control. The facility failed to: Ensure CNAs M and N bagged soiled linen prior to transporting. Ensure CNA O donned PPE properly and performed hand hygiene and glove changes while performing care to a foley catheter. These failures could lead to the spread of infection. Findings included: 1. In an observation and interview on 8/12/2025 at 10:24 AM, CNA N was observed leaving a resident's room with unbagged linen in the B hallway while wearing gloves. CNA N stated that she was assisting a resident with incontinent care and linen change. She stated the facility policy was that soiled linen should be bagged prior to leaving a resident's room and gloves should not be worn in the hallway. She stated she was a in a hurry and did not bag the linen. CNA…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for residents for 1 of 4 rooms reviewed for physical environment. room [ROOM NUMBER] had a broken drawer placed on top of the dresser. This failure could place residents at risk for injury and experiencing a diminished quality of life.Findings included:During an observation on 8/12/25 at 10:55 a.m., a broken drawer with the drawer front of the drawer hanging off and joints bent was located on top of a dresser in room [ROOM NUMBER]. During an interview on 8/12/25 a 10:30 a.m., HSKPR A stated she would notify her supervisor if equipment was broken. She stated she was not aware the drawer was broken. During an interview on 8/12/25 at 11:00 a.m., CNA A stated that maintenance should be notified right away if something was broken so a resident could not get hurt. CNA A stated she would write it down in the maintenance book, and she did not see the broken drawer.During an interview on…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-14 · 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 ensure the assessment accurately reflected the resident's status for 1 of 9 residents (Resident #76) reviewed for assessments. The facility failed to ensure the MDS accurately reflected Resident #76's diagnosis depression. This failure could lead to residents not receiving necessary care. Findings included: Record review of Resident #76's face sheet, dated 8/12/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Parkinson's Disease (a progressive neuromuscular disorder that causes tremors and weakness) and adult failure to thrive (a syndrome of decreased appetite, reduced physical activity and/or cognitive decline). Record review of Resident #76's quarterly MDS submitted 7/4/2025 reflected a BIMS score of 10, indicating moderately impaired cognition. Section I (active diagnoses) of the MDS reflected Resident #76 did not have a diagnosis of any psychiatric/mood disorders. Record review of Resident #76'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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-14 · 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 records review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #10) reviewed for oxygen use.The facility failed to ensure Resident #10 was monitored for oxygen saturation levels per physician's order to maintain oxygen saturations about 92%. This failure could place residents with respiratory illnesses at risk for a decline in health. Findings included: Record review of Resident #10's face sheet, dated 8/14/2025, revealed a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and made it difficult to breathe), atrioventricular block (a condition where the electrical signals in the heart are completely blocked), and peripheral autonomic neuropathy (a condition where damage to the nerves affect the peripheral nervous system). Record review of Resident…

  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 · D2025-08-14 · tag F0805 — failed to prepare food in a form residents can eat — isolated
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 8 residents (Resident #69) reviewed for dietary services. The facility failed to ensure Resident #69 received their prescribed diet (pureed diet) for 08/15/25 lunch meal service. This deficient practice could place residents, who were provided a mechanically altered diet, at risk of choking, aspiration (inhaling food), and diminished quality of life. The findings included: Record review of Resident #69's admission Record, dated 08/13/25, reflected Resident #69 was a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses to include dysphagia (difficulty swallowing), dementia (loss of cognitive functioning), and cognitive communication deficit. Record review of Resident #69's care plan, undated, reflected Resident #69 had a focus [Resident #69] has a diagnosis for Dysphagia:…

  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 · D2025-08-14 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 8 residents (Resident #6) reviewed for clinical documentation and medical records accuracy. The Electronic Health Record for Resident #6 did not reflect a diagnosis of depression on her admission record as was indicated for taking Remeron Oral Tablet 15 MG. Resident #6's care plan did not accurately reflect that she had a history of claiming someone beat her up when no one was around her. This failure could place residents at risk for incomplete or inaccurate clinical records, which could lead to miscommunication, a delay in services, or a potential decline in the resident's health. The findings included: Record review of Resident #6's admission record, dated 08/12/25, reflected Resident #6 was a [AGE] year-old female initially admitted on [DATE] 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

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

Fines & penalties

$199,073 in federal fines across 4 penalties.

• $9,113 — penalty dated 2025-07-31
• $16,149 — penalty dated 2025-03-03
• $93,356 — penalty dated 2025-03-03
• $80,455 — penalty dated 2024-05-30

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 CARADAY HEALTHCARE — 8 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 13 rows in the source record cover these 12 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 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 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