No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Bronte Health and Rehab Center

900 S State St, Bronte, TX 76933 · Government - Hospital district · 55 certified beds · (325) 473-3621 Medicare & Medicaid certified

Call the home — (325) 473-3621 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Sep 2023Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation1 Medicare payment denial
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 Sep 2023
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 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
2626 N Bryant Blvd · (325) 747-2271 · Call to confirm hours
Pharmacy
105 N 13th St · (325) 365-2117 · Call to confirm hours
Grocery
101 S State St · (325) 473-6601 · Call to confirm hours
Park
1402 Austin St · (325) 453-2714 · Typically dawn to dusk
Place of worship
424 S Washington St · (432) 528-0377

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 2 of 5
Short-stay residentsrehab / post-hospital 4 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 4 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 rating4★
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 increased26.7%15.8%15.4%worse
Long-stay residents who lose too much weight7.5%3.0%5.4%worse
Long-stay residents with a catheter left in their bladder1.8%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection10.8%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms3.3%2.4%6.5%worse 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 injury4.2%3.3%3.3%worse
Long-stay residents whose ability to walk worsened32.0%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication15.4%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine95.7%98.0%95.3%typical
Long-stay residents with pressure ulcers5.0%3.8%4.7%typical
Long-stay residents with worsening bladder/bowel control29.4%13.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.6%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents rehospitalized after admission38.9%25.7%22.6%worse
Short-stay residents with an outpatient ER visit9.4%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days1.542.171.67typical
Long-stay outpatient ER visits per 1,000 resident days1.002.061.80better

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.

11.3%U.S. median 10.7%
Went back to hospital
0.12U.S. median 0.31
Therapy hours / resident / day
0.02hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 8.1–18.310.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 worsened0.0%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 hospitalization6.1%CMS range 3.0–13.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.281.02Oct 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

0.86
RN hours/ resident / day
0.68
LPN hours/ resident / day
2.09
Aide hours/ resident / day
3.63
Total nurse hours/ resident / day
0.44
RN hoursweekends
54.3%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 55 beds and averages 35.3 residents a day — about 64% occupied, or roughly 20 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 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.86 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 2.99 hrs/resident/day on weekends vs 3.89 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.03 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% 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

2
deficiencies at the latest standard inspection (2026-01-23)
3
at the previous standard inspection (2024-11-07)

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.

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.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · Gcited before2024-03-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 11 resident (Resident #1) reviewed for accidents. The facility failed to supervise Resident #1 to prevent falls. This failure could place residents who required supervision at risk for falls. The findings included: Review of Resident #1's annual MDS assessment, dated 9/20/23, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was a BIMs of 3. Her diagnoses included Neurocognitive disorder (is a general term that describes decreased mental function due to a medical disease other than a psychiatric illness), epilepsy, muscle wasting and atrophy, and lack of coordination. Review of Resident #1's Care Plan, dated 1/15/2024, reflected she was a fall risk. The Care Plan reflected: the resident was at high risk for falls due to impaired balance, bowel, and bladder incontinence, severe cognitive impairment and poor…

    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 before2026-04-14 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to report the results of an investigation in accordance with State Law within 5 working days of the incident for 1 of 2 incidents (Resident #1) reviewed for reporting. The Administrator failed to report the results of an investigation alleging neglect, after Resident #1 had an unwitnessed fall resulting in fracture, within 5 days to the State Survey Agency. This failure could affect residents if alleged violations are verified, and appropriate corrective actions are not taken.Findings include: Record review completed on 04/13/26 at 09:32am of the TULIP (Texas Unified Licensure Information Portal) system revealed that no Provider Investigation Report (Form 3613-A) had been filed in the system for this allegation of unwitnessed fall. The facility had filed the Facility Reported Incident and CII Self-Report Template on 3/31/2026. Record review of the Provider Investigation Report (form 3613-A) for the facility reported incident that occurred on 3/30/26 revealed that it was completed on 4/14/2026. The Provider Investigation…

    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 · D2026-04-14 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that 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 4 Residents (Resident #1) reviewed for care plans. The facility did not develop and implement a comprehensive person-centered care plan that implemented an intervention to prevent falls for Resident #1's fall. This failure could place residents with falls at risk for further falls and injuries.Findings include: Record review of Resident #1's admission Record, dated 04/13/2026, revealed Resident #1 was a [AGE] year-old female and was admitted to the facility on [DATE]. Resident #1's diagnoses included unspecified fracture of upper end of right humerus subsequent encounter for fracture with routine healing (broken top of right arm bone that…

    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 · D2026-04-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 1 of 2 residents (Residents #2) reviewed for ADL care. The facility failed to provide incontinence care to Resident #2 every 2 hours and as needed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings included: Record review of Resident #2's face sheet revealed a [AGE] year-old female admitted to facility on 2/20/2026 with diagnoses of chronic kidney disease stage 4 (kidneys not filtering waste properly), chronic diastolic heart failure (the left ventricle becomes stiff and fails to relax properly limiting its ability to fill with blood between beats), and morbid obesity (having a body mass index of 40 kilograms or higher). Record review of Resident #2's admission MDS assessment, dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-26 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 update the care plan after quarterly assessment was completed for 1 of 3 residents (Resident #1) reviewed for care plans.The facility failed to update the care plan as there were no interventions to prevent falls added to the care plan for Resident #1's fall sustained on 2.6.26.This failure could place residents at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.Findings included: Record review of Resident #1's detailed summary report/face sheet, dated 2.26.26, indicated she was [AGE] year old female admitted to facility on 12.15.25 with diagnoses of dementia (a progressive, irreversible syndrome characterized by a decline in memory, language, and cognitive function severe enough to disrupt daily life), diverticulosis of intestine (is the formation of small, bulging pouches (diverticula) in the lining of the intestine, most commonly the colon, often due to high pressure…

    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 · Ecited before2026-01-23 · 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 remove expired items, store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services.1. The facility failed to ensure expired items were disposed of properly. 2. The facility failed to ensure pans, strainers, pitchers, cooking and serving utensils, and measuring cups were covered; not open to air.3. The facility failed to ensure drawers, containing cooking and serving utensils and plastic lids, were clean and without food crumbs in the bottom.4. The facility failed to reseal food items that were opened.5. The facility failed to ensure food was frozen or discarded after 48 hours (2 days) after preparation per facility policy.6. The facility failed to ensure foods were labeled properly. These failures could place residents at risk for food borne illnesses.Findings include: During an observation of the kitchen on 01/21/2026 at approximately 9:10 AM, the following were revealed: Dry Storage:1. 5 boxes of corn…

    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 · D2026-01-23 · 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 store all drugs and biologicals in locked compartments in the facility's only treatment cart. The facility failed to ensure RN C secured the facility's only treatment cart when it was left unattended. This failure could place residents at risk for drug diversion or accidental ingestion. Findings included: During an observation and an interview on 01/21/2026 at 8:57 AM, the treatment cart was noted to be unlocked and unsupervised near the nurse's station. Inside the cart were several dressings, medicated ointments, and powders. Approximately 10 minutes later, RN C approached the cart. RN C said the nurses were responsible for ensuring the treatment cart was locked, she did not know why the cart was unlocked and unattended, and she had not used it today. During an observation and an interview on 01/21/2026 at 3:30 PM, the treatment cart was noted to be unlocked and unsupervised outside room [ROOM NUMBER]. Inside the cart were several…

    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 · D2025-07-16 · 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 review, the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 (Resident #1) of 2 residents reviewed for PASRR. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health.Record review of Resident #1's face sheet dated 7.16.25 revealed a [AGE] year-old female who was admitted to the facility on 2.10.25 with diagnoses that included: Metabolic Encephalopathy, mild intellectual disabilities, epilepsy, hypertension, hyperlipidemia (a condition characterized by abnormally high levels of lipids (fats), including cholesterol and triglycerides, in the blood), hypothyroidism (when your thyroid gland doesn't…

    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 · Ecited before2024-11-07 · 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 observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and that the resident environment remained as free of accident hazards as possible for 2 of 5 residents (Resident #13 and Resident #42) reviewed for accidents and supervision. The facility failed to ensure Resident #42 did not have hazardous chemicals in her room unattended. Resident #42 had two bottles of nail polish remover in her room. The facility failed to ensure the staff used a gait belt when walking back from the shower with Resident #13. These failures placed residents at risk of injury due to not being supervised and placed at risk of accidents/hazards. Findings included: Review of Resident #42's admission Record, dated 11/7/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease with Late Onset (a form of dementia). Resident #42 resided on the secured unit. Review of Resident #42's admission MDS assessment…

    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 · Ecited before2024-11-07 · 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 to help prevent the development and transmission of communicable diseases and infections for two (Resident #12 and #28) of 3 residents reviewed for incontinent care in that; CNA A failed to change her gloves once they became contaminated during incontinent care for Resident #12. CNA C failed to change her gloves once they became contaminated during incontinent care for Resident #28. These failures could place resident's risk for cross contamination and the spread of infection. Finding included: RESIDENT #12 Record review of Resident #12s admission record dated 11/06/2024 indicated she was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and muscle weakness. She was [AGE] years of age. Record review of Resident #12's care plan revised date 03/09/23 indicated in part: Focus: Resident has total bowel…

    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 before2024-11-07 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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, interview, and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 3 residents (Resident #28) by 1 of 4 certified staff (CNA C) reviewed for competent staff, in that: CNA C failed to change her gloves once they became contaminated during incontinent care for Resident #28. These failures could place residents at risk for not receiving nursing services by adequately trained and certified aides and could result in a decline in health and infection. The findings were: Record review of Resident #28's admission record dated 11/07/2024 indicated she was admitted to the facility on [DATE]. She was [AGE] years of age with diagnoses of Dementia and chronic obstructive pulmonary disease. Record review of Resident #28's care plan revised date 10/24/24 indicated in part: Focus: I have bowel and bladder incontinence due to impaired cognition and confusion related to Dementia, 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · Dcited before2024-06-09 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law for 2 of 5 residents (Resident #1, Resident #2) reviewed for abuse. The facility failed to report alleged violations related to abuse to HHSC. The facility failed to notify a law enforcement agency of allegations of abuse. This failure could place the residents at risk of sexual abuse. Findings included: Record review of Resident #1's electronic health record revealed a [AGE] year-old female, admission 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-01 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 5 (Residents #1, #2, #3, #4, and #5) of 10 residents reviewed for staffing concerns on the memory care unit. 1. The facility failed to ensure there were sufficient staff to ensure Resident #1 did not sustain falls while on the memory care unit. 2. The facility failed to ensure there were sufficient staff to ensure Residents #1-#5 had the proper assistance per the resident's required assistance. These failures placed residents at risk of not getting needed care and services, a decrease in quality of care and quality of life and/or injury. Findings included: Record review of Resident #1's face sheet, dated 03/29/24, reflected an [AGE] year-old female with an admission date of 3/27/24. Resident #1 had diagnoses which…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-01 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 on psychotropic drugs had the correct diagnosis in place for 1 of 4 residents (Resident #1). The facility failed to ensure that Resident #1 should not have received antipsychotic (ABH gel), without the proper diagnosis in place. This failure could affect residents who received medications in the facility and put them at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. The findings included: Record review of Resident #1's face sheet, dated 03/29/24, reflected an [AGE] year-old female with an admission date of 3/27/24. Resident #1 had diagnoses which included Neurocognitive disorder, collapse, bradycardia, and unsteadiness on feet. Record review of Resident #1's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS score of 3, indicating sever cognitive impairment. Record review of Resident #1's Care Plan dated…

    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 before2024-03-20 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 ensure hospitality aides with the supervision of a CNA can care for resident's needs, as identified through resident assessments, and described in the plan of care for 1 of 4 Residents (Resident #1) in that: 1. The facility failed to ensure CNA C supervised hospitality aide HA B in assisting Resident #1 to the toilet. These deficient practices affect residents who require assistance from trained staff which could contribute to possible adverse reactions. The findings included: Review of an admission Record for Resident #1 dated 3/20/24 reflected she was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Neurocognitive disorder, aphasia, type 2 diabetes, and Parkinson's disease. BIMs of 7 indicating sever cognitive impairment. Review of an annual MDS assessment for Resident #1 dated 1/17/24 reflected, Toilet use: I require limited assistance x1 staff support with toileting task and toilet hygiene. Progress notes 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-13 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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, it was determined the facility failed to accurately assess a resident for risk of entrapment from bed rails, prior to use for one (Resident #1) of 4 sampled residents. Resident #1 had quarter bed rails in use, when there was no side rail assessment completed. This failure had the potential to cause injury to a resident for improper use of bed rails. Findings included: Review of an admission Record for Resident #1 dated 3/6/24 reflected he was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including encounter for surgical aftercare following surgery on the digestive system, anemia, muscle weakness, and unsteadiness on feet. Review of an annual MDS assessment for Resident #1 dated 2/27/24 reflected, the assessment indicated there were no bedrails in use. Resident #1 required 1-2 staff assistance for ADL ' s Review of Resident #1 Care Plan dated 2/27/24 reflected, nothing regarding bedrails in care plan. During an observation on 3/13/24…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-09-29 · 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, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items remain covered during distribution on the hallways. 2. The facility failed to ensure that the dish machine reached the appropriate temperature for sanitization. 3. The facility failed to ensure expired food items were discarded by their expiration date. This failure could affect residents by placing them at risk for contamination by foodborne illness. The findings included: Observation on 09/26/23 beginning at 10:55 AM of dry storage revealed: - 1 box chocolate cake mix with expiration date of 09/07/23 - 1 box cream cheese carrot cake mix with expiration date of 06/13/23 - 1 box cream cheese carrot cake mix with expiration date of 09/07/23 - 1 box cream cheese carrot cake mix with expiration date of 06/09/22 - 1 box cream of rice with expiration date of 09/20/23 Interview on 09/26/23 at 11:40 AM, Dietary Aide G stated the kitchen staff…

    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 · E2023-09-29 · tag F0550 — failed to protect resident dignity and rights — pattern
    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 treat each resident with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for three of seven residents (Residents #6, #15, and #40) reviewed for residents rights, in that: Staff on the secured unit did not serve residents at the same table at the same time. CNA D stood over residents while feeding Residents #40, Resident #15, and Resident #6 who were sitting in their seats. This failure puts residents at risk of feeling embarrassed, infantilized, dehumanized, or stigmatized due to their need for assisted dining. Findings include: Review of Resident #6's admission Record, dated 9/27/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Dementia, stroke, need for personal care, depression and anxiety. Resident #6 resided on the secured unit. Review of Resident #6's quarterly…

    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 · E2023-09-29 · 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 residents had the right to be free from abuse for 2 of 3 residents (Resident #22 and Resident #36) reviewed for abuse. 1. The facility failed to prevent Resident #22 and Resident #36 from verbal abuse from CNA F. This failure could result in verbal abuse to the residents, fear, and isolation. The findings included: Review of Resident #22's admission Record, dated 09/28/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, chronic obstructive pulmonary disease (condition involving constriction of the airways), hypertension (high blood pressure), anxiety, depression, Type 2 Diabetes Mellitus, and left-sided hemiplegia (paralysis of one side of the body) following stroke. Review of Resident #22's Quarterly MDS Assessment, dated 09/20/23, revealed she scored a 15 on her mental status exam (indicating no cognitive deficit), she had no reported behaviors, she required moderate…

    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 · E2023-09-29 · 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

    Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 Medication Carts and 1 Medication Storage Rooms reviewed for pharmacy services. 1. The facility failed to ensure Medication Cart #1 did not include expired Calcium Carbonate (antacid). 2. The facility failed to ensure the Medication Storage Room did not contain expired Cimetidine (antacid), Allergy Relief tablets and Acetaminophen Suppositories. 3.The facility failed to maintain proper temperature in the medication refrigerator in the medication room. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and worsening of symptoms of diseases. Findings Include: In an observation on 09/28/23 at 10:10 AM, Medication Room refrigerator revealed: - temperature reading of 42 degrees Fahrenheit with water found in tray located between…

    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 before2023-09-29 · 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 to help prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Resident #6 Resident #and #94) reviewed for infection control. LVN A failed to clean scissors during wound care for Resident #94 between dirty and clean dressings. CNA D and CAN E did not wash their hands or change gloves between dirty and clean during incontinent care (Resident #6). CNA D touched Resident #40's food with her bare hands MA C put her bare, unwashed hands into a medication crushing bag These failures could place resident's risk for cross contamination and the spread of infection. Findings included: Review of Resident #6's admission Record, dated 9/27/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Dementia, stroke, need for personal 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 respect the resident's right to personal privacy for 2 of 12 residents (Resident #6 and #15) reviewed for privacy issues in that: CNA E and CNA J failed to pull the curtain all the way around during Resident #6's ADL care. This failure could cause residents to feel uncomfortable, disrespected, and possible exposure to anyone passing by. Findings include: Review of Resident #6's admission Record, dated 9/27/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Dementia, stroke, need for personal care, depression and anxiety. Resident #6 resided on the secured unit. Review of Resident #6's quarterly MDS Assessment, dated 7/13/23 revealed: She scored a 5 of 15 on her mental status questionnaire and showed signs of delirium including inattention and disorganized thinking. (Indicated she was not interviewable) She needed extensive assistance of two staff for toileting. She was always…

    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 before2023-09-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #15) reviewed for accident hazards/supervision, in that: CNA E failed to complete a one-person gait belt transfer safely for Resident #15. These failures could place residents at risk for injuries. Findings included: Review of Resident #15's admission Record, dated 9/27/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, psychotic disorder with delusions due to know physiological condition, depression, anxiety, and need for personal care. Review of Resident #15's quarterly MDS Assessment, dated 8/21/23, revealed: She had long and short-term memory impairment with severely impaired decision-making abilities. She showed signs of delirium including inattention and disorganized thinking. (Indicated she was not interviewable) She needed extensive…

    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

“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

No federal fines in the current CMS record. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2026-04-23 for 33 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
MATHIS, JOHNNYIndividualW-2 MANAGING EMPLOYEEsince 06/01/2019
OGBURN, SHELLIIndividualW-2 MANAGING EMPLOYEEsince 10/11/2021

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

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.

$3.5M
Net patient revenuemost recent cost report
-10.7%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 49%Medicare 9%Other / private 42%

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 2024. 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

$268per resident / day
operating cost
$8,152per month
≈ monthly operating cost
$242per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 675681. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-23, 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.

What to do next