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Big Spring Center For Skilled Care

3701 Wasson Rd, Big Spring, TX 79720 · For profit - Corporation · 120 certified beds · (432) 606-5012 Medicare & Medicaid certified

Call the home — (432) 606-5012 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Mar 20241 actual-harm citation$8,184 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,184 in federal fines (most recent 2024-05-14)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (92%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2602 S Gregg Ste 6 · (432) 315-2077 · Call to confirm hours
Pharmacy
2606 S Gregg St · (432) 517-4480 · Call to confirm hours
Grocery
2000 SOUTH GREGG
Park
100 Whipkey Dr · (432) 264-2323 · Typically dawn to dusk
Place of worship

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

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased23.9%15.8%15.4%worse
Long-stay residents who lose too much weight4.5%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.5%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.1%3.3%3.3%worse
Long-stay residents whose ability to walk worsened15.4%14.0%16.1%typical
Long-stay residents on antianxiety or hypnotic medication14.6%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers9.5%3.8%4.7%worse
Long-stay residents with worsening bladder/bowel control12.6%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table15.4%9.6%17.1%typical
Short-stay residents who newly got an antipsychotic medication3.5%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine100.0%88.0%79.4%better
Short-stay residents rehospitalized after admission21.3%25.7%22.6%typical
Short-stay residents with an outpatient ER visit24.9%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.402.171.67better
Long-stay outpatient ER visits per 1,000 resident days3.912.061.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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.

58.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 44 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.6%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
66.7%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.01hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 66.7% 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 21 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF58.6%CMS range 49.1–71.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 7.1–15.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge66.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge61.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge61.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened12.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.211.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.34
RN hours/ resident / day
0.81
LPN hours/ resident / day
2.28
Aide hours/ resident / day
3.43
Total nurse hours/ resident / day
0.20
RN hoursweekends
91.7%
Total nursing turnover
88.9%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 60.6 residents a day — about 50% occupied, or roughly 59 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 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 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 2.97 hrs/resident/day on weekends vs 3.62 on weekdays — 18% thinner on weekends. RN hours go from 0.40 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 92% is well above the national median of 45%. 3 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

4
deficiencies at the latest standard inspection (2026-04-24)
4
at the previous standard inspection (2025-02-27)

Deficiencies are unchanged from the previous inspection. 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.

ABCDEFGHIJKL

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.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · G2024-05-14 · tag F0760 — failed to prevent significant medication errors — isolated
    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 1 of 4 residents (Resident #1) reviewed for medication administration were free of significant medication errors. CMA A on [DATE] administered Resident #2's medications to Resident #1, which caused her blood pressure (BP) to decrease, and she was sent to the hospital. This failure could place residents at risk for receiving medications that were ordered for a different resident and could have possible adverse reactions. Findings included: Record review of Resident #1's Order Summary Report with active orders as of [DATE] indicated she was admitted to the facility on [DATE] with diagnoses of other specified Hypothyroidism (thyroid gland doesn't produce enough thyroid hormone that can disrupt heart rate, body temperature and all aspects of metabolism), need for assistance with personal care, Alzheimer's disease with late onset (progressive decline in episodic memory, with variable involvement of other cognitive domains), Epilepsy (a disorder 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-24 · tag F0813 — pattern
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 4 of 21 residents rooms reviewed for food safety (room [ROOM NUMBER]-1, 309-1, 311-1, and 316-1). 1. The facility did not have a system in place to assist residents in cleaning and maintaining their personal refrigerators to ensure safe food handling and prevent consumption of spoiled and/or expired foods.2. The facility did not have a system in place to ensure the refrigerators were monitored for internal Time Temperature Controlled for Safety cold foods were at 41 F or below.These failures could place residents at risk for food borne illnesses.Findings include:room [ROOM NUMBER]-1 During an observation on 4/22/26 at 10:34 AM, Resident room [ROOM NUMBER]-1 contained a personal refrigerator. The refrigerator contained food items such as five bottles of grape and strawberry jelly, one jar of peanut butter, two jars of swirled peanut butter and jelly, six cans 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-24 · 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 interviews and record reviews, the facility failed to coordinate assessments resident Pre-admission Screening and Resident Review (PASARR) to avoid duplicate test and effort for 1 of 24 residents (Resident #13) reviewed for PASARR screening, in that: Resident #13 did not have an accurate and updated PASARR Level 1 (PL1) assessment reflecting a diagnosis of mental illness. This failure could place residents at risk of not receiving care and services to meet their needs.The findings included:Record review of Resident #13's undated face sheet revealed a [AGE] year-old male, originally admitted to the facility on [DATE]. Resident #13 had a medical history of Parkison's disease (a progressive, incurable neurodegenerative disorder), psychotic disorder with hallucinations due to known physiological condition (a mental health state where hallucinations or delusions are directly caused by a physical illness, brain disease, or injury) diagnosed on [DATE], and anxiety (the body's natural response to 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    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 observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1of 3 Residents (Resident #34) reviewed for incontinent care. CNA A failed to properly clean peri-area (pubis and vaginal area) and buttocks while providing incontinent care to Resident #34. This failure had the potential to affect residents by placing them at an increased risk of exposure to communicable diseases and infections. Findings include: Record review of the admission record for Resident #34, dated 01/30/26, revealed a [AGE] year-old female who was admitted on [DATE] with the following diagnoses: Alzheimer's Disease (cognitive loss) and muscle weakness. Record review of the quarterly MDS assessment for Resident #34, dated 11/22/25, revealed Resident #34 required supervision or touching assistance for toileting hygiene - 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-24 · 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 establish and 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 of 3 residents (Resident #34) reviewed for infection control. CNA A did not perform hand hygiene or gloves changes when providing incontinent care to Resident #34. This failure could place residents at risk for cross contamination and infection. Findings included: Record review of the admission record for Resident #34, dated 01/30/26, revealed a [AGE] year-old female who was admitted on [DATE] with the following diagnoses: Alzheimer's Disease (cognitive loss) and muscle weakness. Record review of the quarterly MDS assessment for Resident #34, dated 12/12/25, revealed Resident #34 required supervision or touching assistance for toileting hygiene - the helper provides verbal cues and/or touching/steadying and/or…

    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 before2025-03-31 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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 implement written policies and procedures that prohibit and prevent abuse and neglect for 2 of 5 residents (Resident #1, and #2) reviewed for abuse. A. The Former ADM (Abuse Preventionist) failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding the Resident-to-Resident altercation (between Resident #1 and Resident #2) that occurred on 3/14/25. B. The facility staff (CNA A, E, and LVN C) failed to follow the facility's abuse policy by not reporting the allegation of abuse to the Former ADM (Abuse Preventionist) regarding the Resident-to-Resident altercation (between Resident #1 and Resident #2) that occurred on 3/14/25. C. The facility (the ADON) failed to follow the facility's abuse policy by not assessing Resident #1 and #2 at the time of a Resident-to-Resident altercation that occurred on 03/14/25. These failures could place residents as risk for abuse and neglect. Findings included: Resident #1 Record…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-31 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 provide the resident and/or resident representative written notice which specified the duration of the bed-hold policy at the time of transfer of a resident for hospitalization for 2 of 5 residents (Resident #2 and #3) reviewed for transfers. The facility did not ensure Resident #2 and her representative were provided with a written bed-hold policy on the following dates when the resident was transferred from the facility: 2/08/25. The facility did not ensure Resident #3 and her representative were provided with a written bed-hold policy on the following dates when the resident was transferred from the facility: 3/17/25. This failure could place residents at risk of being improperly discharged and placed in unsafe conditions. The findings included: Resident #2 Record review of Resident #2's face sheet, dated 03/28/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (memory loss), dementia…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-27 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 21 confidential residents. The facility failed to ensure 12 confidential residents were provided access to the Grievance form and provided the procedure for how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews and record review during Resident Council on, 02/1/2025 at 2:00 p.m., 12 confidential residents, stated they did not have access to the Grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. The Residents did not know they had the right…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-27 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to store and date foods stored in the refrigerator. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 02/25/25 at 09:58 AM during initial observation of the kitchen: Observed the following in the walk-in refrigerator: -Plastic container with mixed fruit open with no label and no date. -Metal bowl covered with tin foil with no label and no date. -Plastic container with lid open with label Taco Bake expired date 02/20. -Plastic container with label Pudding expired date 02/20. -Plastic container with label Mash Potatoes no date. During an interview on 02/27/25 at 10:28 AM with DM, she stated all food in the refrigerator was to be sealed and dated. She stated all food should be thrown out or used by the expired date. She stated…

    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 before2025-02-27 · 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 control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 2 of 3 residents (Resident #40 and Resident #51) and 3 of 6 staff (CNA E, CNA H, and CNA I) reviewed for infection control. 1. CNA E failed to follow policy and procedure for handwashing while providing incontinent care for Resident #40. 2. CNA H and CNA I failed to follow policy and procedure for handwashing while providing incontinent care for Resident #51. These failures could place residents at risk for spread of infection and cross contamination. Findings included: Resident #40 Record review of Resident #40s face sheet dated 02/17/25 revealed a [AGE] year-old male with an original admission date of 05/30/2025 and a readmission date of 02/17/25 with the following diagnoses: pneumonia, acute respiratory failure, sepsis with septic shock (dramatic drop 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-27 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 5 residents (Resident #49) reviewed for PASRR Level I screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #49. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnoses Post-Traumatic Stress Disorder were present upon Resident #49's admission date on 10/07/24. This failure could place residents who had a mental illness at risk of not receiving a needed assessment PASRR Evaluation, individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #49's face sheet, dated 02/27/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE], and readmitted most recently on 01/22/25. Her diagnoses included Post-Traumatic Stress Disorder, epilepsy (seizure disorder), diabetes…

    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
Show the remaining 16 citations
  • Potential for harm · Dcited before2024-10-11 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 prompt efforts by the facility were made to resolve grievances for the residents for 1 of 6 residents (Resident #1) reviewed for grievances. A. The Social Worker failed to ensure a grievance was filled out and followed up on after Resident #1 requested a room change and reported that she felt uncomfortable because of staff working in the facility. This failure could place residents at risk for decreased quality of life and feelings of neglect. Findings included: 1.Record review of Resident #1's face sheet, dated 10/11/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include cognitive communication deficit, muscle weakness and urinary incontinence. Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: *Section B0800. Ability to understand others, Resident #1 had clear speech, could make herself understood and usually understood others. *Section C Brief Interview for…

    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 before2024-10-11 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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 written policies and procedures that prohibit and prevent abuse and neglect for 1 of 6 residents (Resident #1) reviewed for abuse. A. The Social Worker failed to follow the facility's abuse policy by not reporting the allegation/concern to the abuse preventionist when Resident #1 requested a room change and reported that she felt uncomfortable because of staff working in the facility. B. A confidential interview revealed that they did not follow the facility's abuse policy by not reporting the allegation/concern to the abuse preventionist when Resident #1 reported that she felt uncomfortable due to staff treatment from CNA A, CNA D, LVN E, and MA F on an unknown date. C. LVN C failed to follow the facility's abuse policy by not reporting the allegation/concern to the abuse preventionist when an unidentified staff reported that Resident #1 felt uncomfortable/dirty because of staff working in the facility. These failures could…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-14 · 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 notify the resident's physician and representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of four residents reviewed for changes in condition, in that: The facility failed to immediately notify the Physician (MD A) and Responsible Party (RP A) of a medication error that involved Resident #1 receiving resident#2's medication. This error cause Resident #1's blood pressure to decrease, to be administered and IV, and to be sent to the hospital. This failure placed residents at risk of not having physician (MD) and Responsible Party (RP) input and involvement in their care and treatment decisions. Findings included: Record review of Resident #1's Order Summary Report with active orders as of [DATE] indicated she was admitted to the facility on [DATE] with diagnoses of other specified Hypothyroidism (thyroid gland doesn't produce enough thyroid hormone that can disrupt heart rate, body…

    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 before2024-05-14 · 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 interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #3) reviewed for accidents and hazards. NA A used a sliding board to transfer Resident #3 on a sliding board she had not been trained to use. This deficient practice could place residents transferred via sliding board at risk of falls which could result in injury and hospitalization. Findings include: Record review of Resident #3's admission Record indicated he was admitted to the facility on [DATE]. This report included his diagnoses as pressure ulcer of right heel (caused by factors such as pressure shear and friction) and acquired absence of left leg below the knee. Record review of Resident #3's admission Minimum Data Set (MDS) assessment dated [DATE] indicated he scored a 14 on his Brief Interview for Mental Status, which indicated he was cognitively intact. This MDS's Functional Abilities and Goals indicated he used a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-19 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    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 and record review the facility failed to ensure the residents had the right to be free from neglect for 2 of 5 residents (Resident #1, Resident #2), reviewed for neglect. CNA A neglected Resident #1 by failing to provide 1 person assistance and clocking out without informing the oncoming shift when she left Resident #1 alone in the facility shower room. CNA A neglected Resident #2 by failing to provide 1 person assistance when she left Resident #2 in a shower chair alone in his restroom shower area when she took Resident #1 to the shower room down the hall. This failure could affect all residents by placing them at risk of neglect, falls, mental anguish and emotional distress. Findings include: Record review of a face sheet dated [DATE] revealed Resident #1 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the central nervous system), Muscle wasting and atrophy (breakdown of muscles), unspecified abnormalities of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-19 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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 develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of resident and misappropriation of resident property for 2 of 2 residents (Resident #1 and Resident #2) reviewed. CNA A neglected Resident #1 by failing to provide 1 person assistance and clocking out without informing the oncoming shift when she left Resident #1 alone in the facility shower room. CNA A neglected Resident #2 by failing to provide 1 person assistance when she left Resident #2 in a shower chair alone in his restroom shower area when she took Resident #1 to the shower room down the hall. This failure could affect all residents by placing them at risk of neglect, falls, mental anguish and emotional distress. Findings include: Record review of a face sheet dated [DATE] revealed Resident #1 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the central…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 interview and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (Resident #1, Resident #2) in that: CNA A failed to provide Resident #1 adequate supervision by failing to provide 1-person assistance when she clocked out without informing the oncoming shift she had left Resident #1 alone in the facility shower room. CNA A failed to provide resident #2 adequate supervision by failing to provide 1-person assistance when she left Resident #2 in a shower chair alone in his restroom shower area when she took Resident #1 to the shower room down the hall. This failure could affect all residents by placing them at risk of falls, lacerations, fractures and pain. Findings include: Record review of a face sheet dated [DATE] revealed Resident #1 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the central nervous system), Muscle wasting and atrophy…

    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 · E2024-01-25 · tag F0576 — pattern
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure that residents received mail for 9 of 12 residents reviewed for rights to forms of communication for 1 of 1 facility reviewed for mail being delivered on Saturdays. The facility failed to: 1.) Ensure that mail had been delivered to all residents on all days that the United Postal Service delivered mail. This failure could result in a decline in the resident's psychosocial well-being and cause them to feel disconnected from family, friends, and current world issues. The findings include: During a confidential interview on 01/24/2024 at 2:00 PM, 12 residents reported that the facility does not deliver mail on the weekends, the resident stated, We only get mail M-F because offices are closed. An interview with BOM on 01/25/2023 at 9:44 AM revealed the mail will be delivered when it was dropped off by the carrier. BOM stated the mail usually gets to the facility around 5-6 PM, Monday through Friday. BOM stated that the mail was supposed to be delivered on Saturdays, but she has never seen it delivered on Saturdays since…

    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 · E2024-01-25 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 each resident's drug regimen was free of unnecessary medication for 2 of 21 residents reviewed for unnecessary medication (Resident #69 and #123). The facility did not monitor Resident #69 for side effects of the anticoagulation medication Aspirin (blood thinning medication) or Enoxaparin Sodium Injection (a blood thinning medication). The facility did not monitor Resident #123 for side effects of the anticoagulation medication Warfarin (a blood thinning medication). These failures could place the residents at risk for adverse consequences of medication. Findings included: Resident #69 Record review of Resident #69's face sheet dated 01/24/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include atherosclerotic heart disease (buildup of plaques inside the artery), atrial fibrillation (irregular heartbeat), peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), and history…

    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 · E2024-01-25 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 2 of 2 noon meals observed for puree. The facility failed to provide food that was in a form to meet resident needs for 2 of 2 meals observed (01/23/24 and 01/24/24). Foods were not pureed and had chuncks that still had to be chewed. These failures could place residents at risk of decreased food intake, choking and aspiration. The findings included: During an observation on 01/23/24 at 11:15 AM [NAME] A prepared puree BBQ ribs, backed beans, potato salad. Surveyor tasted BBQ ribs had chunks of meat that had to be chewed. The baked beans had large pieces of bean skin and was runny. The potato salad had chunks that had to be chewed. During an interview on 01/24/24 at 06:17 PM [NAME] A stated puree should be mashed potato or pudding consistency. She stated she could not get the BBQ ribs to the consistency she wanted because of the gristle and bones. She stated all puree food items served were…

    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 before2024-01-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services and 1 of 1 dining room observed, in that: 1. The facility failed to ensure foods were processed and pureed under sanitary conditions. 2. The facility failed to ensure foods were served at temperature above 135 degrees Fahrenheit. 3. The facility staff failed to use proper infection control precautions by touching the top of open cups and bowls while serving meal trays during one of one dining observation. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 01/23/24 at 11:15 AM during observation of puree meal preparation: After pureeing potato salad, [NAME] A took processor bowl, lid, and blade to 3 compartments sink and cleaned all 3 parts. [NAME] A took all there parts back to processor base and assembled. Bowl had water in bottom and lid was dripping…

    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 before2024-01-25 · 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 establish and 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. 1. The facility staff failed to use proper infection control precautions by touching the top of open cups and bowls while serving meal trays during one of one dining observation. 2. The facility staff failed to wash their hands before medication administration to Residents #67 and #38. 3. The facility staff failed to use proper infection control precautions when providing incontinence care to Resident #1. These failures could place residents at risk for infection through cross contamination of pathogens. Findings include: During an observation of dining on 1/23/2023 at 12:22 pm. CNA B was observed delivering a resident lunch tray in the dining room. CNA B was seen cupping her hand over the uncovered top of 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-25 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 2 of 2 residents with a urinary catheter (Resident # 17 and Resident #65); in that: 1. The facility failed to ensure catheter drainage bag was covered for privacy. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth The findings include: Resident #17 Record review of Resident #17's face sheet, dated 01/24/24, revealed a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses to include parkinsonism, lack of coordination, dysphagia (difficulty swallowing), and neuromuscular dysfunction of the bladder. Record review of comprehensive MDS assessment dated [DATE] revealed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-25 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 recognize the residents right to formulate an advance directive for one of six residents (Resident #47) reviewed for Do Not Resuscitate (DNR) status. The facility failed to enter a do not resuscitate code status for Residents #47 in his chart between the dates of [DATE] to [DATE]. This failure could place residents at risk of not having their end of life wishes met. Findings include: Record review of the Face Sheet for Resident #47 reflected he was admitted on [DATE] with diagnoses of End Stage Renal Disease. Record Review of physician orders dated [DATE], for Resident #47 reflected an order for full code initiated on [DATE]. Record review of the Care Plan for Resident #47 with a Date Initiated of [DATE] and a Target Date of [DATE] reflected interventions were in place for a full code. Interventions included Request for CPR to be initiated if resident #47 was without a heartbeat or not breathing. Record review of Resident #47's Out of Hospital Do 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    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 observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder, received appropriate treatment and services to prevent urinary tract infections for 1 of 1 residents with a urinary catheter (Resident #65); in that: 1. The facility failed to position the catheter collection bag and tubing in a manner to prevent infections. 2. The facility staff failed to use proper infection control precautions when proving foley care. These failures could place residents at risk for urinary tract infections. The findings include: Resident #65 Record review of Resident #65's face sheet, dated 01/29/24, revealed a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar), morbid obesity, muscle wasting and cognitive communication deficit (impaired thought organization). Record review of comprehensive MDS assessment dated [DATE], revealed Resident # 65 had a BIMS score of 15, indicating the resident's cognition 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
  • Potential for harm · D2024-01-25 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in the cart for 1 of 4 medication carts (med cart on hall 300). CMA B had loose pills in the medication cart assigned to her on hall 300. Medication was identified as Atorvastatin 10 mg and belonging to Resident #17. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions . The findings include: Record Review of Resident #17's face sheet documented he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of: end stage renal disease, muscle weakness, type 2 diabetes, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), high blood pressure, atrioventricular block (a heart rhythm disorder that causes the heart to beat more slowly than it should), cardiac arrythmias (improper beating of the heart, whether irregular, too fast or too slow), low blood pressure, acid…

    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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$8,184 in federal fines across 1 penalty.

  • $8,184 — penalty dated 2024-05-14

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 CREATIVE SOLUTIONS IN HEALTHCARE — 149 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 →

RatingThis homeChain avg
Overall 3 of 52.1+0.9 vs chain
Health inspection 4 of 52.7+1.3 vs chain
Staffing 1 of 51.1-0.1 vs chain
Quality measures 3 of 53.2-0.2 vs chain
The other 148 homes this chain runs (chain average 2.1★, per CMS)
1 of 5Afton Oaks Nursing and Rehabilitation CenterHouston, TX 1 of 5Arlington Heights Health and Rehabilitation CenterFort Worth, TX 1 of 5Beltline Healthcare CenterGarland, TX 1 of 5Bluebonnet Nursing & RehabilitationKarnes City, TX 1 of 5Bluebonnet Point WellnessBullard, TX 1 of 5Brentwood Terrace Healthcare And RehabilitationParis, TX 1 of 5Buena Vida Nursing and Rehab-San AntonioSan Antonio, TX 1 of 5Cottonwood Nursing & RehabilitationDenton, TX 1 of 5Countryview Nursing & RehabilitationTerrell, TX 1 of 5Dogwood Trails ManorWoodville, TX 1 of 5Downtown Health and Rehabilitation CenterFort Worth, TX 1 of 5Estates Healthcare and Rehabilitation CenterFort Worth, TX 1 of 5Fair Park Health & Rehabilitation CenterDallas, TX 1 of 5Five Points Nursing & Rehabilitation of College StCollege Station, TX 1 of 5Five Points at Lake Highlands Nursing and RehabDallas, TX 1 of 5Five Points of PflugervillePflugerville, TX 1 of 5Franklin Heights Nursing & RehabilitationEl Paso, TX 1 of 5Gilmer Nursing & RehabilitationGilmer, TX 1 of 5Grace Pointe Wellness CenterEl Paso, TX 1 of 5Graham Oaks Care CenterGraham, TX 1 of 5Granbury Care CenterGranbury, TX 1 of 5Greenhill VillasMount Pleasant, TX 1 of 5Heritage At Longview Healthcare CenterLongview, TX 1 of 5Huebner Creek Health & Rehabilitation CenterSan Antonio, TX 1 of 5Interlochen Health and Rehabilitation CenterArlington, TX 1 of 5Kenedy Health & RehabilitationKenedy, TX 1 of 5Kennedy Health & RehabLufkin, TX 1 of 5Lake Lodge Nursing & RehabilitationLake Worth, TX 1 of 5Lampstand Nursing and RehabilitationBryan, TX 1 of 5Lancaster Nursing & RehabilitationLancaster, TX 1 of 5Marine Creek Nursing & RehabilitationFort Worth, TX 1 of 5Mesa Vista Inn Health CenterSan Antonio, TX 1 of 5Mountain View Health & RehabilitationEl Paso, TX 1 of 5Navasota Nursing & RehabilitationNavasota, TX 1 of 5Normandy Terrace Nursing & Rehabilitation CenterSan Antonio, TX 1 of 5North Pointe Nursing and RehabilitationWatauga, TX 1 of 5Park Place Care CenterGeorgetown, TX 1 of 5Parkview Manor Nursing and RehabilitationWeimar, TX 1 of 5Peach Tree PlaceWeatherford, TX 1 of 5Pebble Creek Nursing CenterEl Paso, TX

Showing 40 of 148; lowest-rated first.

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

Owner / managerTypeRoleSince
HUGGINS, LINDAIndividualW-2 MANAGING EMPLOYEEsince 10/01/2014
CREATIVE SOLUTIONS IN HEALTHCARE INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2014
BLAKE, GARYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2014
BLAKE, MALISAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/08/2014

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$5.7M
Net patient revenuemost recent cost report
-22.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 72%Medicare 6%Other / private 21%

About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$257per resident / day
operating cost
$7,811per month
≈ monthly operating cost
$210per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676380. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-24, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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