Bluebonnet Point Wellness

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

53.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 190 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 39.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 73 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 0.38 therapist hours per resident per day in 2026Q1 — more than 64% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 50% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 119 beds and averages 97.8 residents a day — about 82% occupied, or roughly 21 beds typically open. It usually has some room. 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 2.80 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.60 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 2.47 hrs/resident/day on weekends vs 2.94 on weekdays — 16% thinner on weekends. RN hours go from 0.43 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 98% is well above the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

34 citations, most serious first. The 16 most serious are shown; the remaining 18 are one tap away and print in full.

• Immediate jeopardy · Kcited before2025-07-28 · tag F0580 — failed to tell family and doctor about changes — pattern
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician and notify the resident representative of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 10 residents reviewed for notification of changes.The facility failed to notify Resident #1's physician when they did not administer his valproic acid, topiramate, levetiracetam, and lacosamide on 07/22/25-07/25/25 as ordered.The facility failed to notify Resident #1's physician after he had a seizure on 07/25/25.The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/22/2025 and ended on 07/26/2025. The facility had corrected the noncompliance before the survey began. Findings included: Record Review of Resident #1's face sheet dated 07/27/25 indicated the resident was a [AGE] year-old male…

  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 · Past Non-Compliance
• Immediate jeopardy · Kcited before2025-07-28 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 1 (Resident #1) of 10 residents reviewed for pharmacy services. The facility failed to order Resident #1's valproic acid, topiramate, levetiracetam, and lacosamide after he re-admitted on [DATE]. Resident #1 had a seizure on 07/25/25. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/22/2025 and ended on 07/26/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization.Findings included: Record Review of Resident #1's face sheet dated 07/27/25 indicated the resident was a [AGE] year-old male with an original admission date of 07/10/2025 and readmission date of 07/22/2025. The resident had diagnoses including…

  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 · Past Non-Compliance
• Immediate jeopardy · J2025-07-11 · 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 observations, interviews and record review the facility failed to ensure a resident environment remained as free of accident hazards as is possible for 1 of 3 residents reviewed for accidents (Resident #1) Resident #1 asked for hot water, MA A heated the water in the microware and did not place a lid on the cup. Resident #1 spilled the water and received a burn on her leg. The facility failed to have measures in place to prevent residents from burns. The noncompliance was identified as Immediate Jeopardy PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 9/1/24 and ended on 9/10/24. The facility had corrected the noncompliance before the survey began. This failure could place resident at risk of suffering, injuries, and hospitalization. Findings included: Record review of Resident #1's face sheet dated 7/11/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses were Cervical disc disorder with myelopathy (compressed cervical spine with a potential for…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2025-07-11 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed for medications (Resident #2). The facility failed to follow their policy on medication administration resulting in a significant medication error. *Resident #2 was readmitted [DATE] and had an order on 12/22/24 for Eliquis to be held until 12/27/24- the order did not have a restart date. *Resident #2 had an order on 12/23/24 to hold Eliquis for 4 days and restart the medication on 12/27/24. *The facility did not resume Resident #2's Eliquis medication and he was sent to the hospital on 1/26/25 with DVT and pulmonary embolism. The noncompliance was identified as Immediate Jeopardy PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 1/26/25 and ended on 2/28/25. The facility had corrected the noncompliance before the survey began. This failure could jeopardized resident heath and could have been terminal. Findings Included: Record review 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.

  Pharmacy Service Deficiencies · Past Non-Compliance
• Immediate jeopardy · Kcited before2025-01-24 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 7 (Resident #1) residents reviewed for quality of care. The facility failed to perform neurological assessments following an incident report dated 1/9/25 indicating Resident #1 had a fall and hit her head resulting in her being hospitalized with a subdural hematoma. The facility failed to recognize a change in Resident #1's level of consciousness resulting in the family requesting for Resident #1 to be sent to the hospital and Resident #1 being admitted to the hospital with a diagnosis of a subdural hematoma. The failures resulted in an identification of an Immediate Jeopardy (IJ) at 11:00 a.m. on 1/23/25. While the IJ was removed on 1/24/25, the facility remained out of compliance with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-04-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing was provided for 1 of 4 residents reviewed for pressure injuries (Resident #3). The facility failed to ensure Resident #3 did not develop a stage II pressure injury to the right heel on 3/25/25 and a stage III pressure injury to the right buttock on 4/8/25 that were not present on her admission to the facility. The facility did not ensure Resident #3 was repositioned to effectively alleviate pressure to right buttock on 4/4/25 and 4/5/25. The facility did not ensure Resident #3 was repositioned to effectively alleviate pressure to the right heel on 4/4/25 and 4/5/25. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: Record review of the face sheet dated 4/4/25…

  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 · D2026-01-15 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 1 of 3 residents reviewed for dignity. (Resident #2) The facility failed to ensure Resident #2 was treated with dignity and respect when LVN A told him he was acting like a 2-year-old. This failure placed residents at risk for diminished quality of life, loss of dignity and decrease in comfort. Findings include: Record review of the undated face sheet indicated Resident #2 was a [AGE] year-old male that admitted [DATE].Record review of the physician's orders dated 1/14/26 indicated Resident #2 had diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (impairments on one side of the body due to brain cell death from interrupted blood flow, a stroke), Bell's Palsy (a sudden temporary facial paralysis or…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-15 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative where there was a significant change in the resident's physical, mental, or psychosocial status and when there was a need to alter treatment significantly for 1 of 2 residents (Resident #1) reviewed for enteral nutrition. The facility failed to notify Resident #1's attending physician when her tube feeding was stopped early due to her diarrhea. The facility failed to notify Resident #1's attending physician when her tube feeding was held due to diarrhea. These failures could place residents at risk for delayed treatment, not receiving necessary treatments and medications, and a decreased quality of life. Findings included: Record review of the undated face sheet indicated Resident #1 was a [AGE] year-old female that admitted [DATE] and readmitted [DATE]. Record review of the physician's orders…

  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 · D2026-01-15 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including the accurate acquiring, administering, and receipt of all drugs and biologicals, to meet the needs of 1 of 2 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure that Resident #1's Atorvastin (for reducing cholesterol), Cetrizine (for allergies), Melatonin (for sleep), Ropinirole (for discomfort of restless legs), Venlafaxine (for depression-mood disorder causing persistent sadness and loss of interest affecting thoughts feelings and daily activities), Depakene (to prevent migraine headaches), Gabapentin (for neuropathy-numbness, tingling, and burning of feet and hands), and Biotin (for moisture in the mouth) were administered per physician's orders. This failure could place residents at risk for not receiving the therapeutic benefit of medications, or at risk of not having accurate records of medication administration.Findings included: Record review of the…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-13 · tag F0640 — isolated
  Encode 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 interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS assessment was electronically transmitted to the CMS System within 14 days after completion for 1 of 6 residents (Resident #74) reviewed for encoding/transmitting assessments.The facility failed on 08/04/2025 to transmit a quarterly assessment to CMS for Resident #74 within 14 days of completion when the assessment was completed on 07/21/2025 by the Corporate RN Assessment Coordinator and the facility submitted the quarterly assessment for Resident #74 to CMS 9 days pass due on 08/13/2025. This failure could place residents at risk of not having records completed and submitted in a timely manner as required.Findings included:Record review of a face sheet dated 08/13/2025 indicated Resident #74 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included aortocoronary bypass graft (a surgical procedure to treat coronary artery disease), congestive heart failure (a chronic…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-13 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 2 of 12 residents (Resident's #4 and #8) reviewed for MDS assessment accuracy.The facility failed to ensure a comprehensive MDS assessment dated [DATE] for Resident #4 captured oxygen use, suctioning, and tracheostomy care.The facility failed to ensure a quarterly MDS assessment dated [DATE] for Resident #8 was not inaccurately coded for tracheostomy, dialysis, and hospice care. These failures could place residents at risk of not receiving adequate care and services to meet their needs. Findings included:1.Record review of a facility face sheet dated 8/13/25 for Resident #4 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia. Record review of a Comprehensive MDS assessment dated [DATE] for Resident #4 indicated a BIMS assessment should not be completed due to resident being rarely/never understood.…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-13 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #36) and 1 of 6 staff (CNA E) reviewed for infection control. The facility failed to ensure CNA E changed gloves when going from dirty to clean and washed or sanitized her hands between glove changes when providing care to Resident #36 on 8/12/2025.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of a facility face sheet dated 8/13/25 for Resident #36 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of dementia.Record review of a Quarterly MDS assessment dated [DATE] for Resident #36 indicated a BIMS score of 06 which indicated she had…

  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 · E2025-07-11 · tag F0627 — pattern
  Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident was oriented with a planned, safe and orderly discharge for 1 of 5 residents reviewed for discharge (Resident #3). Resident # 3 was discharged to the hospital, the facility refused to take him back due to nonpayment. Resident # 3 resided at the hospital for over 30 days until the hospital was able to find placement. This Failure could place residents at risk of not permitting a safe and orderly dischargeFindings included: During an interview on 6/30/25 at 11:42 a.m. the Administrator said there were no records for Resident #3 in their computer system, because he was discharged out of the system prior to their change of ownership on 7/1/24. She said she had to go to the hospital after she started working at the facility because the facility had been blacklisted and the hospital would not refer any residents to them. She said the hospital was upset because the former owners had dumped Resident #3 and refused to take him back. She said…

  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 before2025-04-08 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical needs for 1 of 6 residents (Resident #2) reviewed for comprehensive resident centered care plan. The facility failed to ensure Resident #2 was not care planned for a secured unit when the facility did not have a secured unit. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings Included: 1. Record review of the face sheet dated 4/5/25 indicated Resident #2 admitted to the facility on [DATE] with diagnoses including second cervical vertebrae (the second vertebrae in the spinal column, located in the neck region) with routine healing, surgical aftercare, seizures, hypertension (elevate blood pressure), and shortness of breath. Record review of the MDS dated [DATE] indicated Resident #2 understood others and was understood by others. The MDS indicated Resident #2 had a BIMS…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-08 · 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 observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 1 of 7 (Resident #1) residents reviewed for ADLs. The facility failed to ensure Resident #1 received incontinent care for an episode of urine incontinence on 4/5/25. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings Included: 1. Record review of the face sheet dated 4/7/25 indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including overactive bladder, urinary incontinence, muscle weakness, unsteadiness on feet, and difficulty walking. Record review of the quarterly MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 11 and was moderately cognitively impaired. The MDS indicated Resident #1 required…

  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 before2025-04-08 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record review, in accordance with State and Federal laws, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys on 3 of 7 medication carts reviewed for labeling and storage of medication. The facility did not ensure the medication cart on hall 200 and 2 medication carts on hall 300 were secured and unable to be accessed by unauthorized personnel. This failure could place residents at risk for not receiving drugs and biologicals as needed or a drug diversion. Findings included: 1. During an observation on 4/5/25 at 5:08 a.m. the medication cart on the 200 Hall was in the middle of the hallway unlocked with the keys lying on top of the cart and no staff nearby. During an interview on 4/5/25 at 5:10 a.m. LVN A said she was the nurse for the 200 Hall. LVN A said she did not always leave her medication cart unlocked with the keys on top of the cart. LVN A said a CNA had called her into a resident room to assist with a…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$181,947 in federal fines across 5 penalties.

• $17,279 — penalty dated 2025-07-28
• $16,442 — penalty dated 2025-07-11
• $16,442 — penalty dated 2025-07-11
• $11,781 — penalty dated 2025-04-08
• $120,003 — penalty dated 2025-01-24

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 →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 22 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX