Focused Care at Cedar Bayou

Location & what’s nearby

Open in Google Maps ↗ · Directions ↗ · Larger map ↗

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.

66.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 81 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 125 beds and averages 80.2 residents a day — about 64% occupied, or roughly 45 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 3.01 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 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 2.81 hrs/resident/day on weekends vs 3.09 on weekdays — 9% thinner on weekends. RN hours go from 0.46 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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.

25 citations, most serious first. The 19 most serious are shown; the remaining 6 are one tap away and print in full.

• Immediate jeopardy · Kcited before2025-05-09 · 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 observation, interviews, and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for 1 of 5 residents (CR#1) reviewed for physician notification. The facility failed to properly identify and intervene in CR#1's acute change in condition related to his diabetes mellitus and congestive heart failure. The facility failed to notify physician after CR#1's vitals were declining, which lead to CR#1's hospitalization with vital organ impairment or failure. An Immediate Jeopardy (IJ) was identified on 05/07/2025 at 5:30 p.m. While the IJ was removed on 05/08/2025 at 10:50pm the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could affect residents by…

  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 before2025-05-09 · 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 observation, interviews and record review, the facility failed to ensure CR#1 received treatment and care in accordance with professional standards of practice for 1 of 5 residents (CR#1) reviewed for quality of care. The facility failed to properly identify and intervene in CR#1's acute change in condition related to his diabetes mellitus and congestive heart failure. The facility initially became aware of CR#1's declining vitals on 5/2/25 at 10:18am based on the timeline of vitals listed in nursing notes. 911 was not called until 5/3/25 at 5:30pm, which was more than 24 hours later. An Immediate Jeopardy (IJ) was identified on 05/07/2025 at 5:30 p.m. While the IJ was removed on 05/08/2025 at 10:50pm, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk…

  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 · Kcited before2025-04-16 · 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 comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (CR #1) reviewed for quality care. The facility failed to ensure CR #1 did not receive Hydrocodone-Acetaminophen (Norco) after it was discontinued after her hospital visit on [DATE] but was not discontinued in her chart. CR #1 received Norco more frequently than the order that remained in her chart on [DATE]. She experienced lethargy, nausea, vomiting, and decreased response to stimuli and expired at the hospital later that evening. An Immediate Jeopardy was identified on [DATE] at 4:33 p.m. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy 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
• Immediate jeopardy · Kcited before2025-04-16 · tag F0755 — failed to provide safe pharmacy services — pattern
  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 interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (CR #1) reviewed for pharmacy services in that:. The facility failed to ensure CR #1 did not receive Hydrocodone-Acetaminophen (Norco) after it was discontinued after her hospital visit on [DATE] but was not discontinued in her chart. CR #1 received Norco more frequently than the order that remained in her chart on [DATE]. She experienced lethargy, nausea, vomiting, and decreased response to stimuli and expired at the hospital later that evening. An Immediate Jeopardy was identified on [DATE] at 4:33 p.m. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to 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 date of correction
• Immediate jeopardy · K2025-04-16 · 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 of any significant medication errors for 1 of 5 residents (CR #1) reviewed for significant medication errors. The facility failed to ensure CR #1 did not receive Hydrocodone-Acetaminophen (Norco) after it was discontinued after her hospital visit on [DATE] but was not discontinued in her chart. CR #1 received Norco more frequently than the order that remained in her chart on [DATE]. She experienced lethargy, nausea, vomiting, and decreased response to stimuli and expired at the hospital later that evening. An Immediate Jeopardy was identified on [DATE] at 4:33 p.m. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place the resident at risk for 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-02-12 · tag F0697 — failed to manage pain — pattern
  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, record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 7 residents reviewed for pain management. The facility failed to provide medications Hydrocodone-Acetaminophen 10- 325mg per order for Resident #129 when admitted on [DATE] and after Resident #129 complained of continued pain and requested medication. No pain medication was provided until 2/6/24 when MD visited and changed medication orders. An Immediate Jeopardy (IJ) situation was identified on 2/08/2024. The IJ template was provided to the facility on 2/08/2024 at 3:03 PM While the IJ was removed on 2/12/2024, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need 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
• Immediate jeopardy · Kcited before2024-02-12 · tag F0755 — failed to provide safe pharmacy services — pattern
  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 interview and record review, the facility failed to provide routine and emergency drugs for 1 of 8 residents (Resident #129) reviewed for pharmacy services. -The facility failed to provide Resident #129 with ordered routine medications, Eliquis 5mg (blood thinner) and Hydrocodone-Acetaminophen 10- 325mg (pain medication) upon admission and for two days thereafter resulting in the resident experiencing continued pain. An Immediate Jeopardy (IJ) situation was identified on 2/08/2024. The IJ template was provided to the facility on 2/08/2024 at 3:03 PM. While the IJ was removed on 2/11/2024, the facility remained out of compliance at a severity level of potential harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving their medications as prescribed resulting in decline in health and quality of life. Findings included: Record review of Resident #129's admission…

  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
• Immediate jeopardy · J2024-02-12 · 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 interview, observation, and record review, the facility failed to ensure one of twelve residents (Resident #3) reviewed for abuse, neglect, and/or exploitation remained free of abuse. -Resident #3 alleged that LVN B kicked her in her side/back after she had fallen in her restroom in November 2023 This failure could place residents at risk for abuse, pain, fear, and psychosocial impairment. The noncompliance was identified as PNC. The IJ began on 11/20/2023 and ended on 11/21/2023. The facility had corrected the noncompliance before the survey began. Findings include: Record review of Resident #3's face sheet dated 2/6/2024 revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included dementia (group of symptoms that affects memory, thinking and interferes with daily life), major depressive disorder (MDD, mental health disorder having episodes of psychological depression), a history of falling, cerebral infarction (stroke), unspecified psychosis (symptoms of more…

  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 · J2024-02-12 · 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 provide adequate supervision to prevent accidents for 1 (Resident #18) of 6 residents reviewed for accidents hazards/supervision. The facility failed to prevent Resident #18 from eloping from the facility without the staff's knowledge despite the resident wearing a wander guard. The facility failed to ensure the facility exit doors were secured/locked to prevent resident elopement. An Immediate Jeopardy was identified on 02/08/24. The Immediate Jeopardy was lowered on 02/11/24; however, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of serious injuries due to lack of supervision. Findings include: Record review of Resident #18's face sheet dated 2/8/24…

  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 · D2026-06-18 · tag F0636 — isolated
  Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to transmit accurate, encoded, complete MDS assessments to the CMS system within 14 days of admission for 1 of 17 residents records reviewed for MDS transmission (Residents # 68).The facility failed to ensure that CR 68's admission MDS dated [DATE] was completed within 14 days of admission.This failure put residents at risk of not having their assessments completed timely which could result in denial of services or denial of payment for services. Findings included:Record review of CR #68's face sheet dated 02/06/26 revealed CR #68 was admitted to the facility on [DATE]. Her diagnoses included fracture of right femur, malignant neoplasm unspecified female breast (Breast cancer) diabetes mellitus (body inability to process glucose), dementia, essential hypertension (high blood pressure), major depressive disorder, and muscle weakness.Record review of CR #26's admission MDS dated with ARD date of 02/12/26 revealed the admission MDS was signed as completed 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 · Dcited before2026-06-18 · 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 MDS assessment accurately reflected the resident's status for 1 (Resident #22) of 6 residents reviewed for accuracy of assessments.The facility failed to accurately complete the MDS assessment to indicate Resident #22 did not receive insulin. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Record review of Resident #22's face sheet dated 6/18/2026 revealed she was admitted into the facility originally on 11/16/2018 and readmitted on [DATE] with diagnoses that included Parkinsonism (an umbrella term that refers to conditions with similar, movement-related effects). unspecified diastolic congestive heart failure (when the heart muscle is too stiff to relax and fill properly with blood between beats), unspecified atrial fibrillation (an irregular and chaotic heartbeat.), and obesity (an unhealthy, excessive amount of body fat that increases the risk…

  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 · Dcited before2026-06-18 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  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 its medication error rate was not greater than 5 percent or greater. The facility had a medication error rate of 16.67% based on 5 errors and 30 opportunities which involved 3 of 4 residents (Resident #71, Resident #62, and Resident #11) reviewed for medication administration.1.RN A failed to administer 3 medications separately through Resident #71's gastrostomy tube (G-tube). 2.RN A failed to flush in between administering medications through Resident #11's G-tube. 3.RN B failed to administer the correct order of Senna oral tablet 8.6 mg to Resident #62.RN B administered Senna Plus 50 mg to Resident #62. These failures could place residents at risk of increased hospitalization, adverse side effects, and a decline in health. Record review of Resident #71's face sheet dated 6/17/2026 revealed a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Cerebral Infarction (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 · D2026-06-18 · tag F0880 — failed to prevent and control infections — isolated
  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 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 communicate disease and infections for 2 of 4 residents reviewed for infection control. RN A failed to utilize PPE prior to administering medication to Resident #71 through a gastrostomy tube.RN B failed to use clean technique while preparing medication for Resident # 62 by placing a medication capsule into her left hand before placing the capsule into a medication cup.RN B failed to perform hand hygiene after administering medication and exiting Resident #62's room. This failure could place residents at risk by exposing them to care that could lead to the spread of infection and communicable diseases.Record review of Resident #71's face sheet dated 6/17/2026 revealed a [AGE] year old male originally admitted to the facility on [DATE] and readmitted on [DATE] with…

  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 no plan of correction
• Potential for harm · Dcited before2026-04-22 · 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 interview and record review, the facility failed to immediately consult with the resident's physician and resident's representative when there was a deterioration in the resident's physical and mental status for 1 of 1 CR (CR #1). The facility failed to notify the resident's physician and the resident's representative of CR #1's restless nighttime behavior with repeated attempts to get out of bed and crawl onto the floor, and the need for a mattress on the floor for CR#1 to sleep on. This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. Record review of CR#1's admission record dated [DATE] revealed a [AGE] year old female, admitted [DATE] and discharged [DATE] to the hospital, with diagnoses that included peripheral vascular disease (a slow and progressive disorder of the blood vessels), heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), aphasia (primarily 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-22 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  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 baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of the resident for 1 (CR#1) of 1 resident reviewed for baseline care plans. The facility failed to provide the CR#1's representative with a summary copy of the baseline care plan. The facility failed to incorporate CR#1's sleeping preferences in the baseline care plan. This failure could result in residents not receiving inadequate care or having their needs met. Record review of CR#1's admission record dated 4/21/2026 revealed a [AGE] year old female, admitted [DATE] and discharged [DATE] to the hospital , with diagnoses that included peripheral vascular disease (a slow and progressive disorder of the blood vessels), heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), aphasia…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-09 · tag F0656 — failed to write and follow a full care plan — isolated
  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 interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plans for one (Resident #1) of seven residents reviewed for comprehensive care plans in that: The facility failed to notify the PCP according to the resident care plan and physician orders when Resident #1's blood sugar level was over 401 after a blood sugar level check on 6/9/2025. This failure could place the residents at risk of harm, injuries, and delayed treatment. Findings included: Record review of Resident #1's face sheet, dated 6/11/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 diagnosis was Diabetes mellitus (high blood sugar levels). Record review of Resident #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 9 (moderately cognitive impairment). Section I- Active Diagnoses included diabetes mellitus. Section N - Medications received insulin injections. Record review of Resident #1's care plan, revised on 6/11/2025,…

  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 before2024-02-12 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  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 implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 10 residents (Resident #129) reviewed for care plans, in that: -A baseline care plan was not completed for Resident #129 within 48 hours of admission. This failure could affect all newly admitted residents to the facility by placing them at risk of not receiving the care and services for health promotion and continuity of care. Findings included: Resident #129 Record review of Resident #129's admission Record revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included: metabolic encephalopathy (problem in the brain caused by chemical imbalance in the blood), type 2 diabetes mellitus (the body's impaired used of blood sugar), stroke (impaired blood flow to the brain), chronic gout (a painful condition in…

  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 before2024-02-12 · tag F0656 — failed to write and follow a full care plan — isolated
  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 to develop and implement a comprehensive person-centered care plan consistent with the resident rights and 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 and failed to describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 12 residents (Resident #57) reviewed for care plans. -The facility failed to document the care plan with the use of Resident #57's scoop mattress usage. This failure could place residents at risk of attaining/maintaining their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of Resident #57's face sheet dated 2/9/2024 revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included encephalopathy (…

  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 before2024-02-12 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  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 the medication error rate was not five percent or greater. The facility had a medication error rate of 6 % based on 2 errors out of 32 opportunities, which involved 1 of 8 residents (Resident #64) reviewed for medication errors, in that: MA Q failed to give Resident #64 her Sevelamer Carbonate (a medication used to lower blood phosphorus levels in patients on dialysis due to kidney disease) as ordered by her physician with meals and Carvedilol (medication used to treat high blood pressure and heart failure) as directed by pharmacy with meals. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled health conditions. Findings include: Resident #64 Record review of Resident #64's Face Sheet dated 02/08/2024 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: hypertension (elevated blood pressure blood 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.

  Pharmacy Service 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

$99,628 in federal fines across 4 penalties. 1 Medicare payment denial on record.

• $73,165 — penalty dated 2025-04-16
• $8,821 — penalty dated 2024-02-12
• $8,821 — penalty dated 2024-02-12
• $8,821 — penalty dated 2024-02-12
• Medicare payment denial — starting 2025-05-15 for 43 days

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 FOCUSED POST ACUTE CARE PARTNERS — 25 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 20 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 79% 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. This home reported $311K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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