Avir at Camp Wood
710 Hwy 55, Camp Wood, TX 78833 · For profit - Corporation · 86 certified beds · (830) 597-5445 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $86,254 in federal fines (most recent 2024-02-06)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 2 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 | 9.7% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 10.4% | 3.0% | 5.4% | worse |
| 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 | 0.3% | 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 | 3.9% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 12.3% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 43.3% | 18.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.0% | 3.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 6.6% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 35.1% | 9.6% | 17.1% | worse |
| Short-stay residents rehospitalized after admission | 39.5% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.8% | 12.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.12 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.95 | 2.06 | 1.80 | 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.
Met the expected recovery: 5.0% 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 20 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 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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 | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.7%CMS range 8.4–18.0 | 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 | 5.0% | 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 | 15.0% | 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 | 5.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 | 0.0% | 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 | 11.5% | 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 | 9.1%CMS range 5.2–15.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.69 | 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 86 beds and averages 75.2 residents a day — about 87% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.77 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 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 2.52 hrs/resident/day on weekends vs 2.87 on weekdays — 12% thinner on weekends. RN hours go from 0.29 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
2 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 more than at the previous inspection — worsening. 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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · K2023-11-06 · 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 observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 8 Residents (Residents #1, #2, #5, #6, #7, and #8) reviewed for infection control. 1. The facility failed to place signage on the door indicating Resident #7's need for droplet isolation precautions due to positive COVID-19 status. 2. The facility failed to ensure CNA A and NA B wore a gown, gloves, and goggles or a face shield upon entering Resident #1, #2, #5 and #6's room who was on contact and droplet isolation for COVID-19. 3. The facility failed to ensure NA B used appropriate hand hygiene when exiting a room under contact and droplet precautions and before entering a resident room who had not tested positive for COVID-19 and when touching her own N95 facemask, face and hair. 4. The facility had an outbreak beginning…
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 · E2026-06-12 · tag F0680 — patternEnsure the activities program is directed by a qualified professional.
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 activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the State for 1 of 1 Activity Directors reviewed for qualifications of activity professionals.The facility failed to have a qualified Activities Professional to direct their activities program.This deficient practice could place residents at risk of not receiving activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings include: Record review of the facility assessment dated [DATE] revealed the facility staffing needs required an Activities Director. During an interview on 6/11/2026 at 6:41 p.m. the Activities Director stated she had been a housekeeper and worked as a cashier at a local grocery store before applying for the job as Activities Director. When asked about her previous experience working…
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 · D2026-06-12 · 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 the resident's right to formulate an advance directive for 1 of 4 residents (Resident #1) reviewed, in that:The facility failed to ensure Resident #1's OOH DNR was accurately reflected in her medical record and in her plan of care.This deficient practice could result in residents' end of life wishes being unknown or dishonored.The findings were: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: dementia with behavioral disturbance, type 2 diabetes mellitus and malignant neoplasm of left kidney (cancer of the kidney). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 which indicated a severe cognitive impairment. Record review of Resident #1's signed OOH DNR dated [DATE] was located in a three-ring binder at the nurses station but was not uploaded into the resident's medical record. The OOH DNR indicated Resident…
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 before2026-06-12 · 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, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 4 residents (Resident #1 and #2) reviewed for care plans.1. The facility failed to ensure Resident #1's comprehensive care plan included information accurate DNR status. 2. The facility failed to ensure Resident #2's care plan included mouth pain and ulcers and the need to continue to follow up with medical care and interventions. These failures could place residents at risk for not having their needs and preferences met.The findings include:1. Record review of Resident #1's face sheet dated 6/11/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: dementia with behavioral disturbance, type 2 diabetes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-12 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to assist residents in obtaining routine dental services and emergency dental services including arranging for the transportation to and from the dental services locations to meet the needs for 1 of 2 (Resident #2) residents reviewed for dental services. The facility did not ensure Resident #2 was provided transportation to a dental specialist to address his ongoing mouth infection and ulcers. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. The findings were: Record review of Resident #2's face sheet dated 6/11/2026 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: dementia, type 2 diabetes mellitus without complications, and cellulitis and abscess of mouth. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated the resident was cognitively intact. The assessment indicated the resident…
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 before2026-06-12 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 medical records were maintained in accordance with accepted professional standards and practices for each resident, that were complete and accurately documented for 1 of 4 residents (Residents #1) reviewed for accuracy of medical records. The facility failed to ensure Resident #1's signed and executed OOH DNR was uploaded as part of the resident's medical record. This deficient practice could place residents at risk for errors in care and treatment and inaccuracies in documentation. The findings include:Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: dementia with behavioral disturbance, type 2 diabetes mellitus and malignant neoplasm of left kidney (cancer of the kidney). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 which indicated a severe cognitive impairment. Record review of Resident #1's signed OOH DNR…
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 before2026-01-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 maintain medical records, in accordance with accepted professional standards and practices, that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for documentation. The facility failed to ensure Resident #1 had an accurately documented personal items inventory sheet for admission and discharge.This failure could place residents at risk of missing personal items at admissions, during stay, and at discharge.The findings include: Record review of Resident #1's face sheet, dated 1/15/26 reflected an 83 -year-old female who was admitted to the facility on [DATE] and discharged [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease (a progressive brain disorder), Major Depressive Disorder, and anxiety. The RP was listed as: family member.Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 99 (zero), indicative of severe impairment in cognition.Record review of Resident #1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-08 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed medical records. The facility failed to ensure Resident #1's treatment administration record noted wound care treatments on 7/4/2025, 7/14/2025 and 8/3/2025 as required by the orders noted on the electronic medical record. This failure could place residents at risk of not receiving necessary care and services daily as ordered by the physician to promote proper healing of active wounds.Findings include:Record review of Resident #1's admission record, printed on 12/5/2025, reflected a [AGE] year-old male who was readmitted to the facility on [DATE]. Resident #1 had diagnoses which included type 2 diabetes (a chronic condition that affects the way the body metabolizes sugar leading to high blood sugar levels) with unspecified complications,…
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 · F2025-07-31 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and interviews the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility's reviewed for resources necessary to care for residents competently during both day-to-day operations and emergencies. The facility admitted 79 residents without conducting and documenting a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. This failure could place residents at risk for not receiving competent care during day-to-day operations and emergencies.The findings included: A record review of the facility census dated 7/28/2025 revealed 79 residents resided at the facility. During an interview on 7/31/2025 at 5:00 PM the administrator stated the facility had an assessment of their capabilities and resources however the document resided on the previous administrator's personal computer and efforts to secure 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.
- Potential for harm · Ecited before2025-07-31 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
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 reviews the facility failed to ensure residents had the right to be informed of, and participate in, their treatments, for 3 of 8 residents (Resident #2, #25, and #59) reviewed for informed consent prior to treatment. 1. Resident #2 was administered antipsychotic and antidepression medications, trazodone, divalproex, ziprasidone, and haloperidol, without the resident's informed consent and understanding the medications' potential benefits vs the potential side effects. 2. The facility documented Resident #25's Representative's verbal consent for antiepileptic (seizure) and antipsychotic medications, without a second nurse to witness the consent and sign the consent. 3. The facility documented Resident #59's Representative's verbal consent for antipsychotic medications, without a second nurse to witness the consent and sign the consent. These deficient practices could place residents at risk for harm by therapies with side effects for which they did not consent. 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.
- Potential for harm · Ecited before2025-07-31 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, for 4 of 4 shower rooms in that: 1. The 100-hall shower room had black substance along the edges of the shower room; the baseboards were loose; tiles were cracked and had a dirty appearance. 2. The 300-hall shower room had black substance along the edges of the shower room; the baseboards were loose; tiles were cracked and had a dirty appearance. The 300-hall shower had brown substance on the one of the shower stalls and shower a grate was full of hair. 3. The secure hall shower room had black substance along the edges of the shower room; the baseboards were loose; tiles were cracked and had a dirty appearance. 4. The 400-hall shower room had black substance along the edges of the shower room; the baseboards were loose; tiles were cracked and had a dirty appearance. These failures could place residents at risk of a diminished quality of life due to an unsafe environment. The Findings were: Observation/Interview on 7/29/2025 at…
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 19 citations
- Potential for harm · E2025-07-31 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, for 1 of 1 facility's reviewed for maintenance and operation of essential equipment. The facility failed to maintain operational 1 of the 3 commercial clothes dryers. These failures could place residents at risk for neglect and not having their hygiene needs met.The findings included. During an observation and interview on 7/28/2025 at 3:25 PM revealed the facility's laundry department had 3 commercial clothes dryers. 1 of the 3 dryers was not operational. The Housekeeping director stated the dryer had not been functioning for longer than 3 months and needed to be replaced. During an interview on 7/31/2025 at 5:00 PM the Administrator stated the facility was awaiting the ownership corporation to address the replacement of the commercial clothes dryer. A policy to address essential equipment maintenance was requested. The Administrator stated the facility follows HHSC guidelines. As of 8/5/2025 a policy for maintenance of essential…
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 · D2025-07-31 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 and/or the residents' representatives the right to participate in the development and implementation of his or her person-centered plan of care for 2 of 8 residents (Residents #3 and #79) reviewed for care plans. The facility failed to invite and include the input of Resident #3 and Resident #79 and/or residents' representative as members of the interdisciplinary team in Care Plan Conference meetings. This failure could place residents at risk of not receiving the interventions, treatments, and care necessary for the resident to reach their highest practicable physical, mental, and psychosocial well-being by not involving the resident and/or the residents' representative in Care Plan Conference meetings. The findings included: Record review of Resident #3's face sheet, dated 7/31/25 revealed a [AGE] year-old female admitted [DATE] with diagnosis including anemia (a deficiency of red blood cells), schizophrenia (a disorder that affects…
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 · D2025-07-31 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 inform each Medicaid-eligible resident, in writing, when the resident becomes eligible for Medicaid of those other items and services that the facility offers and for which the resident may be charged for 2 of 2 (Residents #1 and #16) residents reviewed in that: 1. Resident #1 did not provide the cost of Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN). It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. 2. Resident #16 did not provide the cost of Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN). This failure could affect residents who use skilled services and could place them at risk of not being aware of changes to provided services. The Findings were: 1. Record review of Resident #1's admission Record dated 7/31/2025 reflected she [AGE] years…
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 · D2025-07-31 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 from chemical restraints with adequate monitoring for 1 of 8 residents reviewed for abuse, neglect and exploitation. The facility failed to ensure Resident #79 had monitoring for antidepressant medication (Paroxetine). These failures could place resident at risk for adverse drug reactions (unintended, harmful events attributed to the use of medication. The findings included: Record review of Resident #79's face sheet, dated 7/30/25 revealed a [AGE] year-old female admitted [DATE] with diagnoses including Osteoporosis (a condition in which bones become weak and brittle), cerebral infarction (a condition where a part of the brain id damaged due to a blockage of blood flow), insomnia (a sleep disorder), anxiety, major depressive disorder, dysphagia (difficulty swallowing), dementia (a group of conditions characterized by impairment, memory loss, judgement), ataxia (impaired balance 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.
- Potential for harm · D2025-07-31 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 observations, interviews, and record reviews the facility failed to ensure that residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 of 3 residents reviewed for indwelling urinary catheter care. The facility placed Resident #70's indwelling urinary catheter urine collection bag higher than Resident #70 bladder while in his wheelchair. This failure could place residents at risk for harm by urinary tract infections.The findings are: A record review of Resident #70's admission record dated 7/31/2025 revealed an admission date of 7/6/2022 with diagnoses which included retention of urine and obstructive and reflux uropathy (a blockage in the urethra that makes it difficult or impossible to urinate. It can also cause pain and infections.) A record review of Resident #70's annual MDS assessment dated [DATE] revealed Resident #70 was an [AGE] year-old male admitted for LTC related to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-31 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 effective pest control program so that the facility is free of pests and rodents for 1 of 4 shower rooms. The 100 hall-shower room had 3-4 roaches scattering, when the light was turned on. This failure could result in illness and/or psychosocial harm for residents living in areas with insects. The Findings were: Observation and interview on 7/29/25 at 11:45AM with Resident #16 said the Shower room in 100-hall was dirty and needed to be refurbished. Observation of the 100-hall shower room revealed 3 or 4 live roaches scattering when light was turned on. Observation\interview on 7/29/25 at 11:50 AM with the Laundry/Housekeeping Supervisor/Maintenance Supervisor confirmed the scattered roaches in the 100- hall shower room. The ]Laundry/Housekeeping Supervisor stated they will clean the shower room and call pest control. The Maintenance Supervisor stated the pest control company comes once a month. Interview on 7/31/2025 at 2:50 PM the DON and Corporate nurse stated, he will have staff clean 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.
- Potential for harm · E2024-05-31 · tag F0775 — patternKeep complete, dated laboratory records in the resident's record.
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 file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory for 5 of 8 residents (Residents #49, #1, #48, #66, and #15) whose labs were reviewed in that: 1. Resident #49 had lab results sent to the facility on 2/20/2024 not uploaded as of 5/28/2024 [98 days after receipt], resulting in an auxiliary provider not having the information for dietary consultation. 2. Resident #1 had lab results sent to the facility on 9/28/2023 not uploaded as of 5/28/2024 [243 days after receipt]. 3. Resident #48 had lab results sent to the facility on 2/20/2024 not uploaded as of 5/28/2024 [98 days after receipt]. 4. Resident #66 had lab results sent to the facility on 2/20/2024 not uploaded as of 5/28/2024 [98 days after receipt]. 5. Resident #15 had lab results sent to the facility on 2/20/2024 not uploaded as of 5/28/2024 [98 days after receipt]. This failure could place residents at risk of not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-28 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents had the right to be informed of, and participate in, his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment and treatment alternatives or treatment options to choose the alternative or option he or she preferred for 2 of 4 residents (Resident #1 and Resident #2) reviewed for resident rights. 1. The facility failed to obtain consent for the use of sedatives, hypnotics, antidepressants, and antipsychotic medication for Resident #1. 2. The facility failed to obtain consent for the use of antipsychotic, Zyprexa, for Resident #2. These failures could place residents at risk of receiving a medication without consent, which could cause duplicate therapy, sedation, side-effects, and uncomfortable emotional changes. The findings included: 1. Record review of Resident 1's face sheet dated 11/21/2023 revealed an…
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 · E2023-11-28 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 of 7 residents (Resident's #1, #2, and #3) reviewed for activities. The facility failed to ensure there were organized activities provided to residents of the secured unit. This failure could place residents at risk for a diminished quality of life, isolation, lack of stimulation, and a decline in mental status. The findings included: Record review of the November activity calendar posted on the hallway wall in the secured unit revealed: -11/21/2023- 9:30 a.m. Men's Group, 10:00 a.m. outdoor meditation, 2:30…
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 · E2023-11-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 4 residents (Resident #2 and #4) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #2 did not elope from the facility on 10/21/2023. 2. The facility failed to ensure Resident #4 did not elope from the facility on 8/27/2023 These failures could place residents at risk for elopement and could result in injury or a decline in health. The findings included: 1. Record review of Resident #2's face sheet dated 11/22/2023 revealed an admission date of 6/26/23 with diagnoses which included: Huntington's Disease, anxiety disorder, and major depressive disorder. Record review of Resident #2's care plan dated 7/11/2023 revealed the resident did not have a plan of care to include her risk for elopement or actual elopement on 10/21/2023. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score 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.
- Potential for harm · E2023-11-28 · tag F0839 — patternEmploy staff that are licensed, certified, or registered in accordance with state laws.
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 professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 4 staff (Staff C) reviewed for staff qualifications . The facility failed to ensure Staff G completed the appropriate educational requirements of a bachelor's degree in social work and was appropriately licensed to practice social work in the State of Texas. This failure could place residents at risk of not receiving care and services from staff who were properly trained and supervised. The findings included: Record review of Staff G's personnel file revealed: date of hire 9/19/2022 with position hired listed as Social Worker signed by the HR Director. There was no signed job description and no license to practice as a Social Worker in the State of Texas. During an interview on 11/27/2023 at 4:59 p.m., Staff G stated she was working in social services as the Social Services Director at the facility but had not completed her training and did not graduate with her bachelor's degree until May of 2024. Staff G…
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 before2023-11-28 · 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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents' mental, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #2) reviewed for care plans. The facility failed to ensure Resident #2's care plan indicated her risk for elopement or interventions following an actual elopement. This failure could place residents at risk of not receiving appropriate care to prevent elopement. Record review of Resident #2's face sheet dated 11/22/2023 revealed an admission date of 6/26/23 with diagnoses which included: Huntington's Disease (progressive degeneration of the nerve…
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 · D2023-11-28 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 1 of 4 residents (Resident #1) reviewed for medically related social services. The facility failed to ensure a Social Worker assisted Resident #1 in obtaining a legal guardian to look after his best interest and make medically related medical decisions for the resident. This deficient practice could place residents at risk of unmet needs due to insufficient medically related social services. The findings included: Record review of Resident 1's face sheet dated 11/21/2023 revealed an admission date of 3/29/2021 with readmission date of 9/17/2023 with diagnoses which included: Parkinson's disease, psychotic disorder with delusions due to known physiologic condition, mood disorder due to known physiological condition, post-traumatic stress disorder, social and emotional deficit following nontraumatic…
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 before2023-03-31 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 1of 4 Halls (300 Hall/Secure Unit) observed for environmental conditions, in that: The 300 Hall/Secure Unit had a strong urine odor for 4 out of 4 days during the survey. These deficient practices could place residents at risk of decline in health due to unsanitary conditions. The findings include: Observation on 3/28/2023 at 10:10 a.m. revealed a strong urine odor on the Secure Unit. Observation on 3/29/2023 at 3:10 p.m. revealed a strong urine odor on the Secure Unit. Observation on 3/30/2023 at 2:50 p.m. revealed a strong urine odor on the Secure Unit. Observation on 3/31/2023 at 2:28 p.m. revealed a strong urine odor on the Secure Unit. In an interview on 3/30/23 at 2:53 p.m. with CNA B reported the Head CNA (name unknown) had spoken to the aides on the 300 Hall about trying to stay on top of keeping residents dry on the secure unit because of the increased urine odor. In an interview on 3/31/23 at…
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 · E2023-03-31 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 2 of 24 (Resident #3 and #50) residents reviewed for PASRR, in that. 1. The facility failed to refer Resident #3 for PASRR Level 2 assessment when a diagnosis of mood disorder was diagnosed after admission on [DATE] and a diagnosis of psychotic disorder was diagnosed after admission on [DATE]. 2. The facility failed to refer Resident #50 for PASRR Level l2 assessment when a diagnosis of anxiety disorder was diagnosed after admission on [DATE] and manic episode was diagnosed after admission on [DATE]. This failure could affect residents with mental illnesses and place them at risk of not being assessed to receive needed services. Findings include: 1. Record review of a face sheet dated 3/31/23, revealed Resident #3 was an [AGE] year-old female admitted on [DATE] with diagnoses of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-31 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living were provided with the necessary services to maintain good personal hygiene for 4 (Resident # 8, Resident # 32, Resident #20, and Resident #19) of 4 residents reviewed for ADL care, in that: The facility failed to ensure that Residents #8, #32, #20, and #19 were provided bathing as scheduled: 1. Resident #8 missed 3 of 13 scheduled baths between 3/01/2023 and 3/30/2023. 2. Resident #32 missed 13 of 13 scheduled baths between 3/01/2023 and 3/30/2023. 3. Resident #20 missed 4 of 13 scheduled baths between 3/01/2023 and 3/30/2023. 4. Resident #19 missed 9 of 13 scheduled baths between 3/01/2023 and 3/30/2023. This deficient practice could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services to meet their needs and not reaching their highest practicable physical and psychosocial well-being. The findings…
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 · D2023-03-31 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 complete a comprehensive assessment of 1 of 24 residents (Resident #4) in that 1-The facility failed to do a comprehensive assessment for Resident #4 that included her hand and arm tremors. This deficient practice could place residents at risk of receiving inadequate assessments that are not individualized to their care needs. The findings included: 1-Record review of Resident #4's face sheet, dated 3/30/23, revealed the [AGE] year old resident was admitted to the facility on [DATE] with diagnoses including schizophrenia ( a mental disorder affecting the ability to think, feel, and behave clearly), type 2 diabetes (a condition that affects the way the body processes blood sugar), and heart failure (a condition in which the heart doesn't pump blood as well as it should). Record review of Resident #4's MDS, dated [DATE], revealed a BIMS score of 12, indicating moderate cognitive impairment. The MDS did not include any assessment of Resident #4's hand 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 · Dcited before2023-03-31 · 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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 of 24 residents (Resident #64) reviewed for care plans, in that: 1. The facility failed to develop a comprehensive care plan that addressed Residents #64's anti-coagulant therapy. This deficient practice could place residents at risk of receiving inadequate interventions that are not individualized to their care needs. The findings included: 1. Record review of Resident #64's face sheet, dated 3/28/23, revealed the [AGE] year old resident was admitted to the facility on [DATE] with diagnoses including: acute respiratory failure with hypoxia,( a condition in which there is not enough oxygen getting into the blood), Emphysema, ( a lung condition that causes shortness of breath), and type 2 diabetes, (a condition that affects the way the body…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-31 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, record review, and interview, the facility failed to store all drugs and biologicals in locked compartments in 1 of 5 medication storage carts (300/400 Nurses Medication Cart) observed for drug security in that: The 300/400 Nurses Medication Cart was left unattended and unlocked in a public, common area. This deficient practice could place residents and visitors at risk of medication misuse and diversion. During an observation and interview on 3/28/2023 at 2:26 PM, the 300/400 Nurses Medication Cart was observed to be unlocked and unattended at the half wall surrounding the nurses' station. The 300/400 Nurses Medication Cart was observed to have prescription and over the counter medications. Residents, staff and visitors were observed in the immediate vicinity. The LVN responsible for the cart stated the cart had been left unlocked only for a few minutes while she sat down for a moment to take a breather between rounds at the nurse's station. The LVN stated from where she was sitting, she could not see that this surveyor had opened the drawers containing…
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
$86,254 in federal fines across 2 penalties.
- $5,698 — penalty dated 2024-02-06
- $80,556 — penalty dated 2023-11-06
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 AVIR HEALTH GROUP — 116 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 | 1 of 5 | 2.3 | -1.3 vs chain |
| Health inspection | 2 of 5 | 2.4 | -0.4 vs chain |
| Staffing | 1 of 5 | 1.8 | -0.8 vs chain |
| Quality measures | 2 of 5 | 3.6 | -1.6 vs chain |
The other 115 homes this chain runs (chain average 2.3★, per CMS)
Showing 40 of 115; 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 |
|---|---|---|---|
| 700 12TH STREET PROPERTY OWNER, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 03/01/2025 |
| WELLTOWER INC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 03/01/2025 |
| WELLTOWER NNN GROUP, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 03/01/2025 |
| WELLTOWER OP, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 03/01/2025 |
| APOLINAR, ADAM | Individual | CORPORATE OFFICER | since 03/01/2025 |
| CONTRERAS, TERRI | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/29/2019 |
| 710 HWY 55 OPCO, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2025 |
| CORRIGAN, LORI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/16/2024 |
| FREUND, NOCHUM | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 03/01/2025 |
| PREDDY, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2025 |
| TRAVITSKY, AARON | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 03/01/2025 |
| DAGAN, AMITAI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 04/24/2025 |
| GOLDBERGER, ABRAHAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 04/24/2025 |
CMS files one row per role, so the 22 rows in the source record cover these 13 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.
5 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.
About 84% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.
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 675931. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-31, 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.