Oak Ridge Manor
2501 Morris Sheppard Drive, Brownwood, TX 76801 · For profit - Limited Liability company · 114 certified beds · (325) 643-2746 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- it has an abuse, neglect, or exploitation citation (F0602), cited Aug 2023
- 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
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $129,761 in federal fines (most recent 2024-11-21)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (96%) 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 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 1 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.5% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 3.0% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 2.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.6% | 3.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 0.0% | 14.0% | 16.1% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 16.5% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.3% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 0.0% | 13.4% | 21.2% | check this* — see note marked star below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.0% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 34.2% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.5% | 12.3% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
59.2% 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 60 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 87.8% 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 49 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 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 59.2%CMS range 48.5–69.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 7.0–15.0 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 87.8% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 85.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 77.5% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.8%CMS range 6.2–15.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 114 beds and averages 51.5 residents a day — about 45% occupied, or roughly 62 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 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.74 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 2.68 hrs/resident/day on weekends vs 3.54 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.80 to 0.66 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 96% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · F2025-12-30 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 6 of 6 kitchen staff (DC -E, DC-F, DS-G, DS-H, DS-I, and DC-J) reviewed for qualified dietary staff.The facility failed to ensure that DC-E, DC-F, DS-G, DS-H, DS-I, and DC-J met the requirements for food handling by obtaining a current and valid Food Handler's Certificate.This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food born illnesses.The findings included:Record review of food handlers certificates posted in the main dining room was dated as follows:- DC-E -09/27/2022,-DC-F 12/16/2022,-DS-G 09/27/2022,-DS-H 11/28/2022,- DS-I 12/04/2022, and-DC-J did not have a food handler's certificate posted. All certificates indicated that the certificate was valid for 3 years.During an interview on 12/30/2025 at 10:54 am, the DM stated he was responsible for ensuring the dietary staff's food handler's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-30 · tag F0880 — failed to prevent and control infections — patternProvide 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 observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 (CNA-A, CNA-B and CNA-C) staff observed during incontinent care for 2 (Res #4 and Res. #5) of 2 residents. The facility failed to ensure CNA-A, CNA-B, and CNA C performed proper peri-care (incontinent care) and proper hand hygiene during peri-care for Resident #4 and Resident # 5. These failures placed residents of the facility at risk of infections from improper incontinent care and hand hygiene while performing incontinent care.Findings included: Resident #5Record review of the Resident #5's Face Sheet dated 12/30/2025, revealed she was a [AGE] year-old female. Resident #5 had diagnoses of a fractured shaft of left radius, muscle wasting and lack of coordination. Record review of Resident #5's 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.
- Potential for harm · Dcited before2025-12-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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, interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 16 residents (Residents #5) reviewed for care plans. The facility failed to ensure Resident #5 had a care plan in place for an indwelling urinary catheter and a fractured left radius (the bone on the thumb side of the forearm) in a cast and sling. This failure could place residents at risk of not receiving individualized care and services to meet their needs.The findings included the following:Record review of Resident #5's electronic face sheet, dated 12/30/2025, revealed a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE] with medical diagnoses of fracture of the left radius, weakness, high blood pressure, difficulty walking, difficulty speaking, obstructive…
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.
- Potential for harm · Ecited before2024-09-24 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #34, Resident #50) of 5 residents reviewed for comprehensive person-centered care plans. 1. The facility failed to develop care plans based on assessed needs for diagnosis of Type II Diabetes Mellitus, and Interventions for Suprapubic catheter not followed. 2. The facility failed to develop care plan based on assessed needs for weight loss and Knee immobilizer. These failures could affect the residents by placing them at risk for not receiving care and services to meet their needs. The findings included: 1. Record review of Resident #34's electronic face sheet revealed: [AGE] year-old female admitted [DATE] with diagnoses of Unspecified fracture of shaft of let fibula,…
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.
- Potential for harm · E2024-09-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 3 of 3 residents (Residents #50, #258, and #8) reviewed for indwelling urinary catheter. 1. The facility failed to ensure Resident #50's and Resident #258's catheter bag was off the floor and protect from potential contaminants on the floor. 2. The facility failed to ensure Resident #50, Resident #258, and Resident #8 had a related diagnoses for urinary catheter in the physician orders This deficient practice could place residents with indwelling urinary catheters at-risk for urinary tract infections and/or pain. Findings included: Resident #50 Review of Resident #50's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis to include: Dysfunction of the bladder, dementia, and brain bleed. Review of Resident #50's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 3 (Resident #259, Resident #8, and Resident #32) of 3 residents reviewed for respiratory care. 1. The facility failed to obtain a Physician's order for Resident #259's continuous supplemental oxygen. 2. The facility failed to ensure Residents #8's nasal cannula and Resident #259's nebulizer was kept in a bag while not in use. 3. The facility failed to ensure Resident #8's and Resident #32's humidifier bottles (bottled water) were changed out weekly per physician orders. These failures could place residents who received oxygen therapy at risk of oxygen toxicity, respiratory infections, nose bleeds, and nasal discomfort. Findings included: Resident #259 Review of Resident #259's electronic face sheet revealed a [AGE] year-old…
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.
- Potential for harm · F2023-08-16 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 for 1 of 1 kitchen reviewed, in that: The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods. These failures could place residents at risk for food borne illness and cross-contamination. Findings included: An observation on 08/13/2023 at 10:20 AM, of the dry storage revealed: 1. 1 gallon bag of cooked cornbread not labeled or dated. 2. 1 gallon bag of dry toast not labeled or dated. 3. 1 gallon bag of croissants not labeled or dated. 4. 1 opened bag of powdered creamer not sealed or dated. 5. 1 opened bag of instant peppered old fashioned biscuit gravy mix with expiration date of 06/19/2023, not sealed or dated. 6. 1 opened bag of cornbread mix with expiration date of 05/25/2023, not sealed or dated. 7. 1 pan of sealed 1 oz containers of brown sugar not labeled or dated. 8. 1 small 8 oz container of white sugar with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-16 · tag F0607 — failed to have anti-abuse policies — patternDevelop 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 reviews, the facility failed to implement written policies and procedures that protected residents from abuse, neglect, exploitation of residents, and misappropriation of resident property for 3 of 15 employees (ADM, LVN A, and LVN B) reviewed for EMR/NAR's. The facility failed to conduct an EMR/NAR check ADM for 18 months from hire date of 02/14/22 to 08/12/23. The facility failed to conduct an EMR/NAR check on LVN B annually since her hire date of 07/26/22. The facility failed to conduct an EMR/NAR check on LVN C annually since her hire date of 01/09/18. These failures placed residents at risk of abuse, neglect, exploitation and misappropriation of property. Findings included: Personnel File review on 08/16/23 revealed: ADM hire date of 02/14/22 with an EMR/NAR EMR/NAR check on 08/14/23, with an 18-month space between initial and current EMR/NAR. LVN B was hired on 07/26/22 with her initial EMR/NAR checked on 06/20/22 and no further EMR/NAR checks. LVN C was hired on 01/09/18…
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.
- Potential for harm · E2023-08-16 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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 the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents for 6 (08/09/23, 08/10/23, 08/11/23, 08/12/23, 08/13/23, and 08/15/23) of 16 days reviewed for DON coverage. The facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on 08/09/23, 08/10/23, 08/11/23, 08/12/23, 08/13/23, and 08/15/23. This failure leaves residents without the nursing administrative oversight that only the DON can provide. Findings include: During an interview on 08/13/2023 at 10:15 am, the Area Director of Operations stated the DON would not be available for the next 2 days due to having to work night shift as a charge nurse. Review of daily staffing schedule revealed DON worked as a charge nurse on 08/09/23, 08/10/23, 08/11/23, 08/12/23, 08/13/23, and 08/15/23. During an interview on 08/15/23 at 05:20 PM, the Administrator stated the failures noted in the facility were because the DON, ADON, and treatment…
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.
- Potential for harm · E2023-08-16 · tag F0760 — failed to prevent significant medication errors — patternEnsure 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 observations, interviews, and record reviews, the facility failed to ensure residents are free of any significant medication errors, for 4 of 8 Residents (Resident #31, Resident #18, Resident #276, and Resident #29) reviewed for medication administration. 1. The facility failed to administer 7 doses of Creon (medication used to help digest food for people with pancreas issues and gastric issues) to Resident #31 due to medication not being available, but MAR indicated 3 of those doses were administered when they were not. 2. The facility failed to administer 4 doses of Empagliflozin (medication used to lower blood glucose) to Resident #18 due to medication not being available and did not monitor blood glucose per physicians' orders. 3. The facility failed to administer 6 doses of Albuterol Sulfate (medication used to help with breathing for people with lung disease) and 6 doses of Symbicort (medication used to help with breathing for people with lung disease) to Resident #276 due to medication not being…
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.
Show the remaining 5 citations
- Potential for harm · E2023-08-16 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled and discarded when expired in accordance with currently accepted professional principles and the open date and expiration date when applicable for 1 of 3 medication carts (medication cart on 100 hall) reviewed for labeling and storage. The facility also failed to store all drugs and biologicals in locked compartments for 2 (medication cart 100 hall and medication cart 200 hall) of 3 medication carts reviewed for medication storage. The facility failed to discard expired insulin for Resident # 10 from 100 hall medication cart. The facility failed to properly label insulin with open date for Resident # 6 from 100 hall medication cart. The facility failed to properly label insulin with open date for Resident # 40 from 100 hall medication cart. This failure could place residents who receive medications at risk for receiving outdated medications which could result in residents not receiving the intended therapeutic effects of their medications 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.
- Potential for harm · Ecited before2023-08-16 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 (RN-A, LVN-B, and NA-G) staff observed during medication administration and incontinent care. 1. The facility failed to ensure RN-A sanitized the glucometer before or after use on a resident. 2. The facility failed to ensure RN-A did not sanitize the blood pressure cuff before or after use on a Resident #29. 3. The facility failed to ensure LVN-B did not sanitize blood pressure cuff or use hand hygiene during medication pass. 4. The facility failed to ensure NA-G did not perform proper peri-care (incontinent care) or proper hand hygiene for Resident #13. These failures placed residents of the facility at risk of infections from medication administration and incontinent care. Findings included: Record Review of the resident #13's Face Sheet dated 08/14/2023, revealed she was an 84 yr. old…
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.
- Potential for harm · D2023-08-16 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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 ensure residents have the right to formulate an advance directive for 2 of 24 residents (Resident #07, Resident #276) reviewed for advanced directives. The facility failed to have an Advanced Directive, Out of Hospital Do Not Resuscitate (OOHDNR) consent form which includes a Representative and physician signature and License # in the electronic charting or admission paperwork for Resident #07 and Resident #276. This failure could affect residents by not having their preferences honored concerning advanced directives. Finding included: Record review on [DATE] of the electronic face sheet revealed Resident #7 was an [AGE] year-old female, admitted on [DATE] with DNR status and a diagnosis of encephalopathy (A disorder of the brain that can be caused by disease, injury, drugs, or chemicals) and Congestive Heart Failure. Residents Brief Interview of Mental Status (BIMS) assessment on [DATE] was 11 (moderately impaired). Resident physician's orders 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.
- Potential for harm · D2023-08-16 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 reviews, the facility failed to ensure residents the right to be free from misappropriation of property for 1 of 24 (Resident #15) reviewed for personal property. The facility failed to maintain a system to prevent Resident #15's personal money from being taken by a staff member. This failure placed residents at risk of loss of personal property and financial hardship. Findings included: Record review of Resident #15's Facesheet dated 08/16/23 revealed an [AGE] year-old male admitted to the facility on [DATE]. He had a diagnosis list that included: COPD (Primary), Generalized anxiety, Depression. Record review of Resident #15's admission MDS dated [DATE] revealed a BIMS of 9 meaning moderate cognitive impairment. He needed extensive 2-person assistance for most ADL functions, an indwelling catheter and was continent of bowel. Record review of Resident #15's Care plan dated 07/07/23 revealed no care areas regarding personal funds. Record review of PIR dated 07/25/23…
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.
- Potential for harm · D2023-08-16 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 17 (Resident #14) reviewed for MDS information. The facility failed to encode, complete and submit a discharge MDS for Resident #14. This failure could place residents at risk of facilities have provided resident specific information for payment and quality measure purposes. Findings included: Record review of Resident #14's Facesheet dated 08/16/23 revealed an [AGE] year-old female that discharged on 05/05/23. Record review of Resident #14's Care plan last revised 03/01/23 revealed: Resident #14 wishes to return home. Establish a pre-discharge plan with resident/family/caregivers) and evaluate progress and revise plan. Evaluate and discuss with resident/family/caregivers the prognosis for independent or assisted living. Identify, discuss and address limitations, risks, benefits and needs for maximum…
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.
“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.
- 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.
Fines & penalties
$129,761 in federal fines across 1 penalty.
- $129,761 — penalty dated 2024-11-21
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.1 | +0.9 vs chain |
| Health inspection | 4 of 5 | 2.7 | +1.3 vs chain |
| Staffing | 1 of 5 | 1.1 | -0.1 vs chain |
| Quality measures | 4 of 5 | 3.2 | +0.8 vs chain |
The other 148 homes this chain runs (chain average 2.1★, per CMS)
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 / manager | Type | Role | Since |
|---|---|---|---|
| BOWERS, SEAN | Individual | MANAGING CONTROL - GOVERNING BODY | since 07/01/2024 |
| CISNEROS, ALFRED | Individual | MANAGING CONTROL - GOVERNING BODY | since 02/18/2008 |
| COBB, TRAVIS | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/05/2022 |
| COOPER, STEPHEN | Individual | MANAGING CONTROL - GOVERNING BODY | since 11/22/2022 |
| HARDIN, SHERRIE | Individual | MANAGING CONTROL - GOVERNING BODY | since 09/04/2024 |
| KERZEE, RICHARD | Individual | MANAGING CONTROL - GOVERNING BODY | since 09/24/2007 |
| KORENEK, PATRICIA | Individual | MANAGING CONTROL - GOVERNING BODY | since 05/05/2018 |
| SOECHTING, PAUL | Individual | MANAGING CONTROL - GOVERNING BODY | since 11/22/2024 |
| STRACK, JOE | Individual | MANAGING CONTROL - GOVERNING BODY | since 02/11/2022 |
| HUGGINS, LINDA | Individual | CORPORATE DIRECTOR | since 09/01/2020 |
| WILLIG, ZACHARY | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| THOMPSON, JOHNNY | Individual | CORPORATE OFFICER | since 01/01/2024 |
| BROWNWOOD II ENTERPRISES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/24/2025 |
| BLAKE, GARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2020 |
| BLAKE, MALISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2020 |
| CLEVELAND-ALLEN, CHELSEY | Individual | ADP OF THE SNF | since 04/24/2025 |
| MORALES, DAVID | Individual | ADP OF THE SNF | since 01/01/2025 |
CMS files one row per role, so the 19 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
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
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
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.
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 675944. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-30, 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.