7Risk Axes

National percentile · lower = less risk · staffing gap is context only (not in composite)

How we calculate
SeverityElevated

85th national percentile — 12.0% high-severity citations

ChronicityElevated

87th national percentile — 9 repeat citations

Staffing integrityClean

None on file

Fire safetyElevated

13 citations

Weekend staffing dropElevated

82th national percentile — 20.4%

Contract staff shareLow

17th national percentile — 0.0%

Clinical trendElevated

70th national percentile — 2/5 measures worsened

Staffing gapWatch

Reported 3.61 vs expected 3.82 · −0.21 hr/res/day

Recent Health Violations

Health inspection citations from official Medicare records

25 citations on file
F-0677
E
Provide care and assistance to perform activities of daily living for an…
Potential Harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey date: May 30, 2025 · Pattern — no actual harm with potential for more
F-0880
D
Provide and implement an infection prevention and control program
Minimal Harm

Provide and implement an infection prevention and control program.

Survey date: May 30, 2025 · Isolated — no actual harm with potential for more
F-0842
D
Safeguard resident-identifiable information and/or maintain medical reco…
Minimal Harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey date: May 30, 2025 · Isolated — no actual harm with potential for more
F-0761
E
Ensure drugs and biologicals used in the facility are labeled in accorda…
Potential Harm

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.

Survey date: May 30, 2025 · Pattern — no actual harm with potential for more

Recent Fire Safety Violations

Fire safety inspection citations from official Medicare records

13 citations on file
F-0363
E
Install corridor and hallway doors that block smoke
Potential Harm

Install corridor and hallway doors that block smoke.

Survey date: May 30, 2025 · Pattern — no actual harm with potential for more
F-0741
E
Have posted "No-smoking" signs in areas where smoking is not permitted o…
Potential Harm

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Survey date: May 30, 2025 · Pattern — no actual harm with potential for more
F-0222
F
Add doors in an exit area that do not require the use of a key from the …
Potential Harm

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Survey date: Mar 28, 2024 · Widespread — no actual harm with potential for more
F-0293
E
Have properly located and lighted "Exit" signs
Potential Harm

Have properly located and lighted "Exit" signs.

Survey date: Mar 28, 2024 · Pattern — no actual harm with potential for more

Better Nearby Options

Within 25 km · sorted by overall risk percentile

Full nearby list
Facility
CMS
Risk %ile
Tier
AVIR AT BAY CITY
1.2 km · BAY CITY, TX
★★
CMS
53th
Risk %ile
Similar risk
Matagorda Nursing & Rehabilitation Center
3.5 km · Bay City, TX
★★
CMS
53th
Risk %ile
Similar risk