Park Manor Bee Cave

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.

43.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 115 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 63.6% 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 55 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 0.76 therapist hours per resident per day in 2026Q1 — more than 93% 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 140 beds and averages 120.4 residents a day — about 86% occupied, or roughly 20 beds typically open. It runs fairly full. 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 3.07 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.75 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 2.64 hrs/resident/day on weekends vs 3.25 on weekdays — 19% thinner on weekends. RN hours go from 0.46 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as 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.

37 citations, most serious first. The 17 most serious are shown; the remaining 20 are one tap away and print in full.

• Immediate jeopardy · K2024-07-21 · 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, and record review, the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice for two (Resident #1 and Resident #2) of four residents reviewed for pain. The facility failed to provide effective pain management for Residents #1 and #2 as they went multiple days without their pain medication leaving them in excruciating pain. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/19/24 at 3:00 PM. While the IJ was removed on 07/21/24 at 12:50 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. This failure placed residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life. Findings included: Resident #1 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-07-21 · 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 observation, interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for two (Resident #1 and Resident #2) of four residents reviewed for pharmaceutical services. The facility failed to ensure Residents #1 and #2's pain medication was ordered in a timely manner. On several occasions they went without their pain medication subsequently leaving them in excruciating pain. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/19/24 at 3:00 PM. While the IJ was removed on 07/21/24 at 12:50 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. This failure placed residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life. Findings included: Resident #1 Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted 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
• Actual harm · Gcited before2025-09-10 · 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 receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 6 residents reviewed for quality of care. The facility failed to ensure Resident #1's brief was changed, and she was put back in bed after she was transferred to her wheelchair on [DATE] at 8:45 AM until approximately 6:00 PM which resulted in skin breakdown on her sacral area. This failure could place residents at risk of not receiving adequate care, harm, or injuries. Findings included: Review of Resident #1 face sheet dated [DATE] reflected a [AGE] year old female admitted on [DATE] and discharged on [DATE] with diagnoses of dysphagia (difficulty swallowing), aphasia following nontraumatic subarachnoid hemorrhage (difficulty with speaking due to brain bleed), tracheostomy status (surgical procedure that creates an opening in windpipe to help…

  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 · Hcited before2025-05-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide safe and appropriate respiratory care for a resident when needed.
  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 who needed respiratory care were provided with such care, consistent with professional standards of practice for one (Resident #1) of three residents reviewed for respiratory care. The facility failed to ensure nurses were documenting the oxygen flow rate or response to oxygen therapy for Resident #1. The facility failed to have an ongoing system of monitoring Resident #1 as her oxygen saturations dropped below 92% on several occasions, she could no longer participate in therapy, her CO2 lab value was 40 (normal range was 23-31), and she continued to be short of breath days prior to hospitalization on 04/12/25 where she was diagnosed with acute and chronic hypoxic (low levels of oxygen in your body tissues) and hypercapnic (an excess of carbon dioxide in the blood stream) respiratory failure and CHF exacerbation. This deficient practice could place residents at risk for inadequate care, respiratory distress, and hospitalization.…

  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 before2025-04-29 · 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 interview and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services. The facility failed to ensure Resident #1 was administered her prescribed Keppra (anticonvulsant), Buprenorphine (for pain), and Buspirone (for depression and anxiety) until five hours after the scheduled administration time on 04/22/25 causing her to be in increased pain, anxiety, and continuous spasms in her legs. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a group of disorders that affect movement and muscle tone or posture), major depressive disorder, post-traumatic stress…

  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
• Actual harm · Hcited before2023-11-16 · 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, observation, and record review, the facility failed to provide accurate and timely pharmaceutical services to meet the needs of each resident, in that: Three residents (Resident #1, Resident #2, Resident #3) out of six reviewed had not consistently received medications ordered to meet their needs. The facility failed to acquire and administer prescribed drugs as ordered; Resident #1 had not received all doses of his Triamcinolone Cream as ordered, Resident #2 had not received all doses of her sleep-aide medication (Temazepam) and pain medication (Norco) as ordered, and Resident #3 had not received all doses of her pain medication (Morphine Sulfate) as ordered. This failure resulted in unnecessary discomfort and pain, psychosocial distress, and insomnia (trouble falling asleep, staying asleep, or getting good quality of sleep). Findings Included: 1.Record Review of Resident #1s face sheet, dated 11/16/23, reflected a [AGE] year-old admitted on [DATE] from Acute Care Hospital after a diagnosis…

  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
• Actual harm · Hcited before2023-10-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  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 a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of three residents reviewed for indwelling urinary catheters, in that: The facility failed to change Resident #1's foley catheter bag or collect a specimen from him for urinalysis according to physician orders. This failure could place residents with indwelling urinary catheters at risk of sepsis, renal failure, urinary tract infections, and pain. Findings Included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including morbid obesity, spinal stenosis (a condition where the space for the spinal cord and nerves in the spine becomes narrow causing pressure and pain), and muscle wasting and atrophy (wasting away). Resident #1 was discharged from the facility on 09/13/23. Review of Resident #1'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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-07-01 · 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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to update Resident #1's code status on her care plan based on her wishes and OOH DNR signed by her legally authorized representative. This failure could place residents at risk of individualized medical and nursing needs not being met resulting in injury and the residents' end-of-life wishes not being respected.Findings included: Record review of Resident #1's face sheet dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included acute respiratory failure with hypoxia (low oxygen in the body's tissues), pneumonia (infection in 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each 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 ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for one (1) of five (5) residents (Resident #1) reviewed for reasonable accommodation of needs. The facility failed to ensure CNA C was not wearing earbuds while working on the floor on 02/10/2026 and failed to assist Resident #1 to bed when requested. This failure had the potential to place all residents at risk of not having their needs met timely and decreased dignity.Findings include: Record review of Resident #1's Face Sheet, dated 02/19/2026, reflected the resident was an 86 year old female who admitted on [DATE] and readmitted on [DATE]. Diagnoses included morbid severe obesity; type 2 diabetes mellitus with diabetic neuropathy (nerve damage due to prolonged high blood sugar levels); generalized anxiety disorder; monoplegia of the upper limb (type of paralysis that affects one arm); other abnormalities of gait 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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-09-17 · 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, interviews, and record reviews, 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 infection control. The facility failed to maintain infection control practice and proper hand hygiene when preparing meals. These failures could place residents at risk for consuming contaminated food and developing foodborne illnesses. Findings Included: An observation was conducted on 09/17/2025 at 11:15AM in the kitchen. During the observation, [NAME] A had started the meal preparation for the puree foods. [NAME] A had put on a pair of gloves and placed the menu item food into the blender. When the menu item, bread, was pureed, [NAME] A removed their gloves, rinsed their hands off and grabbed new gloves. [NAME] A did not wash their hands or use hand sanitizer after removing the gloves. After [NAME] A put the new gloves on. [NAME] A washed, rinsed, and sanitized the blender. [NAME] A then removed his gloves and placed them into the trash can, grabbed new gloves…

  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 before2025-09-17 · 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 observations, interviews, 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 for 3 of 8 residents (Residents #44, #45 and #74) and 2 of 4 medication carts (100/300-hall nurses' cart and 600-hall med aide' cart) reviewed for pharmacy services. A) The facility failed to ensure expired medication Refresh eye P.M. Ointment for Resident #44 opened on 8/10/25, was removed from the 600-hall med aide medication carts after 30 days of opening. B) The facility failed to ensure an expired medication bottle of nitroglycerin tablets sublingual 0.4 mg was removed from the 100/300-hall nursing cart.C) The facility failed to ensure an insulin pen for Resident #74 was labeled with an open date. The failures could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose, and/or contamination from…

  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 · Dcited before2025-09-17 · tag F0761 — failed to label and store drugs safely — isolated
  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 observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to the keys for 1 of 6 medication and treatment carts. The facility failed to ensure that a treatment cart located in the activity room area between the 100 and 200 halls was locked with keys left on the cart accessible to anybody including residents in the facility. The failure could place residents at risk of injury if medications and biologicals left unsecured were consumed.During an observation on 09/15/2025 from 09:31 PM - 10:05 AM revealed a nurse's treatment cart was left unlocked and unattended with keys left on the top of the cart near the activity room between the 100 and 200 halls. During the observation multiple nursing staff passed the cart without securing the cart and taking the keys. At 10:05 AM the MDS nurse approached the cart and secured it and took the keys with her. The cart drawers were opened by the surveyor to verify that the cart was unlocked. 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-09-10 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 1 (Resident #2) of 6 residents observed for infection control. The facility failed to ensure RN G performed hand hygiene before and during tracheostomy care glove changes for Resident #2. The facility failed to ensure RN G did not test the yankauer in an open container of clear fluid and then suction Resident #2. The facility failed to ensure RN G sanitize the area prior to placing sterile supplies for tracheostomy care performed for Resident #2. These failures placed residents at an increased risk of exposure to infections, development of infections, decreased quality of life and/or hospitalizations.Findings included: Review of Resident #2 face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  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 who needed respiratory care were provided with such care, consistent with professional standards of practice for three (Resident #2, Resident #3, and Resident #4) of six residents reviewed for respiratory care. The facility failed to ensure RN G did not test the yankauer (tool for suctioning) in an open container of water prior to suctioning Resident #2's tracheostomy. The facility failed to ensure RN G monitored Resident #2's oxygen during tracheostomy care. The facility failed to ensure RN G did not continue with tracheostomy care when the yankauer was not functioning for Resident #2. These failures could place residents at risk of inadequate care, respiratory distress and hospitalization. Review of Resident #2's face sheet dated 09/09/2025 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of anoxic brain damage (occurs when brain is deprived of oxygen for an extended period), acute respiratory…

  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 · D2025-08-18 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  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 coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program under Medicaid to the maximum extent practicable to avoid duplicative testing and efforts and did not incorporate the recommendations from the PASRR evaluation report into the resident's assessment, care planning, and transition of care for 1 of 1 resident (Resident #1) reviewed for PASRR. The facility failed to submit a complete and accurate request for Nursing Facility Specialized Services (NFSS) in the LTC Online Portal within 20 business days after the Interdisciplinary Team (IDT) meeting for Resident #1. This failure could place residents at risk of not receiving necessary care or specialized services, which could diminish their quality of life and ability to achieve the highest practical level of functioning.Record review of Resident #1's admission record, dated 08/18/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE].…

  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 · D2025-06-02 · 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 when there was a significant change in the resident's mental and psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for one (Resident #1) of four residents reviewed for notification of changes. The facility failed to immediately notify the physician/provider when Resident #1 was found with the belt of her robe around her neck and tied to her bed rail on 05/31/2025. This failure could result in decreased continuity of care, and a delay in needed treatment and services. Findings include: Review of Resident #1 face sheet dated 06/02/2025 reflected a 52- year-old woman re-admitted on [DATE] with original admission date of 02/25/2025 with diagnoses of bipolar disorder (mental health condition characterized by extreme mood swings), generalized anxiety disorder (mental health condition characterized 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
• Potential for harm · D2025-01-10 · 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 have assessments that accurately reflected the status for one (Resident #1) of five residents reviewed for assessment accuracy. The facility failed to ensure Resident #1's transfer status was accurate in her MDS as it did not reflect she required a mechanical lift. This deficient practice could result in errors in care and treatment. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including displaced comminuted fracture of shaft of right femur (thigh bone), unsteadiness on feet, and muscle wasting and atrophy (wasting away). Review of Resident #1's admission MDS assessment, dated 11/04/24, reflected a BIMS score of 12, indicating a moderate cognitive impairment. Section GG (Functional Abilities) reflected she was dependent with transfers, utilized a manual wheelchair, and did not require a mechanical lift. Review of Resident #1's admission care…

  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

$19,608 in federal fines across 2 penalties.

• $6,338 — penalty dated 2025-04-29
• $13,270 — penalty dated 2024-07-21

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 THE ENSIGN GROUP — 342 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 12 rows in the source record cover these 7 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.

This home reported $746K 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