Mesa View Senior Living
106 Teas Circle, Canadian, TX 79014 · Government - Hospital district · 48 certified beds · (806) 323-6453 Medicaid only — no Medicare
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (98%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 1 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 | 1 of 5 |
| Long-stay residentspeople who live here | 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 held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 19.9% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.8% | 3.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.6% | 0.8% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 5.4% | 2.4% | 6.5% | worse than state‡ — see note marked double-dagger 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 | 6.7% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 13.7% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.9% | 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 | 2.3% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 28.3% | 13.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 27.2% | 9.6% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.54 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.00 | 2.06 | 1.80 | worse |
‡ 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.
Staffing
How full it usually is: this home is certified for 48 beds and averages 40.5 residents a day — about 84% occupied, or roughly 8 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 5.17 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 4.01 is at or above 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 5.01 hrs/resident/day on weekends vs 5.23 on weekdays — 4% thinner on weekends. RN hours go from 0.46 to 0.25 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%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · E2025-12-05 · tag F0578 — failed to honor advance directives / code status — patternHonor 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 observation, interview, and record review, the facility failed to ensure residents or their representative had properly completed Out-of-Hospital Do-Not-Resuscitate(OOH-DNR) form which requires the document to be properly completed and signed, including the notary's date of completion for 4 (Residents #2, # 4, #8, and #11) of 17 residents reviewed for advanced directives.Residents #2, # 4, #8, and #11's DNR form in their record was missing the date of when the notary signed the form.This failure could place residents at risk of receiving medical treatment inconsistent with their or their legal representatives expressed wishes.Findings included:Resident #2Record review of Resident #2's face sheet revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to included but not limited to epilepsy (seizure disorder), unspecified, chronic kidney disease (loss of kidney function) and essential hypertension (high blood pressure). Resident #2 was listed in Advance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-05 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 4 kitchens reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated in House A kitchen. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: Observation of the freezer in House A on 10/13/25 at 10:30 AM revealed the following:1. (1) pie shell, open to air, with no label or date, not in original box.2. (1) package of diced potatoes, not labeled and open to air. 3. (1) Ziplock baggie of frozen cookie dough, no label, not in original box. 4. (1) brown bag of unknown food item, open to air, not labeled, not in original box5. (1) brown bag of unknown food item, not labeled, not in original box 6. (1) Ziplock bag of onions, not labeled, not in original box.7. (1) Ziplock bag of pastry sheets, open to air, not labeled, not in original box8. (3) Ziplock bags 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 · D2025-12-05 · 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 implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #4 and #32) of 17 Residents reviewed for comprehensive care plans. -The facility failed to address the use of oxygen in Resident #4 and Resident #32's care plans. This failure could result in residents not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being.Findings included: Resident #4: Record review of Resident #4's face sheet dated 10/13/2025 revealed an [AGE] year-old female resident admitted to the facility originally on 1/27/2025 and readmitted on [DATE] with diagnoses to include…
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 · D2025-12-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #32) of 17 residents reviewed for respiratory care. -Resident #32 was not receiving oxygen at the correct dose. This failure could affect residents by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition. Findings included: Record review of Resident #32's face sheet dated 10/13/2025 revealed an [AGE] year-old female resident admitted to the facility originally on 3/06/2019 and readmitted on [DATE] with diagnoses to include Alzheimer's (a progressive disease that destroys memory and other important mental functions), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), Bipolar disorder (a disorder associated with episode of mood swings…
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 before2025-12-05 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 service to include accurate dispensing and administering of biologicals for 1 of 7 insulins reviewed to meet the needs of each resident. The House B medication cart had an inulin bottle that expired according to the date documented on the bottle of when it was opened. This failure could result in ineffective treatment resulting in exacerbation of residents' disease processes.Findings included: During an observation on [DATE] at 11:27 AM the House B medication cart revealed 1 [NAME] insulin marked with opened/access date of [DATE] (35 days from [DATE]). RN A reported the insulin pen marked opened/access [DATE] expired, that an insulin should be discarded 28 days after it was opened/accessed, and that the resident involved receives a scheduled dose every evening. RN A immediately discarded the insulin pen and opened a new one. RN A marked the new insulin pen with the opened/accessed date. RN A reported that using 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 · Ecited before2024-12-12 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure that all foods served to residents were labeled and dated as to when they were received and/or opened. The facility failed to ensure food packaging was properly closed and not open to air. This failure could place residents at risk of food-borne illness. Findings included: An initial tour of the kitchen was conducted on 12/10/2024 at 10:22AM and the following was noted: (1) 4-pound bag dry of cheesecake filling mix-no date received. (1) 10-pound bag of tri-colored rotini-no date received. (1) partial 2-gallon zip closure bag of spaghetti noodles-no date received. (1) partial 10-pound box of cracker crumbs-no date received. (1) 36-ounce box of wild rice blend-no date received. (13) individual packages of Oreo cookies-no date received. (2) 2-pound and (1) partial 2-pound bags of fresh grapes-no date received, and no date opened.…
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 · D2024-12-12 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 120 days (8/24/24) of RN schedules reviewed for RN nurse coverage. The facility failed to ensure there were at least 8 hours of RN coverage on August 24, 2024. This failure could place residents at risk of receiving improper care in the event of an emergency and a diminished quality of life. Findings include: A record review of RN coverage for August, September, October, and November 2024, indicated on 8/24/24 there was no RN in the facility for a 24-hour period. An interview with the DON and ADM on 12/11/2024 at 11:50 AM, revealed there had not been an RN in the building on August 24, 2024. The ADM stated the facility did not have policy and procedures in place regarding RN coverage, other than the state and federal regulations. The DON stated the negative outcome of not having an RN in the facility for at least 8 consecutive hours, 7 days a week was residents who needed advanced care beyond the scope of an LVN, would 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 · Dcited before2024-12-12 · 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, interview, and record review the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 1 of 3 (Sunset House ) medication carts observed for . The facility failed to dispose of Bisacodyl Suppositories that expired on 11-2024 in the medication cart located at the Sunset House. This failure could place residents receiving medications at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, or receiving expired medications. Findings included: During an observation and interview on 12-11-2024 at 7:09 AM, of the Sunset House medication cart with LVN A, observation of middle drawer holding Bisacodyl Suppositories 10mg, expiration date 11/2024. LVN A stated she must have missed taking out the medication. LVN A took the medication out of the cart to be destroyed. During an interview on 12-11-2024 at 10:13 AM, LVN A stated that she was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-08 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 procedures that assure the accurate acquiring, receiving, dispensing, administering, and documentation of all drugs and biologicals) to meet the needs of 1 out of 5 residents (Resident #1) reviewed for medication administration, in that: CMA B administered medications to Resident #1 via crushed medications in yogurt with whipped cream and left Resident #1 unattended with the yogurt/medication mix. This was stated by CMA B during conversation with Investigator on 7/8/24 at facility and a written statement by CMA B. This failure can affect residents that receive medications resulting in adverse reactions to medication, deterioration in their health, exacerbation of their disease process, and/or hospitalization. Findings include: Interview with Administrator on 7/8/24 indicated that CMA B wrote a statement about crushing Resident#1's medications and putting them in yogurt with whipped cream, feeding…
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 · E2023-12-05 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews and record review, the facility failed to establish and maintain an infection 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 2 of 2 households (Bldg A and Building E) observed for sanitation and COVID protocols in that: Bldg A and Bldg E did not follow infection control policies related to sanitation and COVID- 19 transmission-based precautions for households and residents that were COVID- 19 positive. This failure could place residents at risk for infections, contamination, physical decline, and hospitalization. Findings included: An observation on 12/5/23 at 10:55 AM revealed no signs for donning and doffing PPE or transmission-based precautions on door. No PPE supplies were observed outside of Resident #1's room. An observation on 12/5/23 at 11:00 AM revealed CNA B in the dining room with 4 residents. CNA B sanitized hands, moved Resident's chair to another area of the table, walk into the kitchen and obtained two…
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 6 citations
- Potential for harm · Fcited before2023-11-16 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 4 kitchens observed. Staff members failed to practice hand hygiene between plates during lunch service and wear hairnets while in the kitchen. This failure can place residents at risk for infection and cross contamination. Findings included: The following actions were observed in Bldg H: Observation on 11/14/23 at 12:03 PM: CNA D who completed hand hygiene touched scrubs, hair, and face, then delivered plates to residents in the dining room. Observation on 11/14/23 at 12:08 PM DON and CNA D delivered plates with no ABHR or hand washing. Observation on 11/14/23 at 12:09 PM DON delivered another plate, no ABHR; CNA D touched resident chair and clothing. Did not use ABHR prior to delivering food. LVN C touched chair and delivered plate without using ABHR. Observation on 11/14/23 at 12:09 PM CNA D delivered plate to resident. CNA D touching glasses and face then delivered food to resident without…
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 · E2023-11-16 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to make prompt efforts to resolve grievances for 9 of 12 anonymous residents reviewed for resident rights. The facility did not make prompt efforts to follow through on grievances made for staff being on the phone or proper food temperatures when served. This failure could place residents at risk of weight loss, emotional distress, and decreased quality of life. Findings Included: An observation on 11/14/23 at 10:50 AM showed [NAME] D observed in Bldg E talking to someone on the phone via a pink headset that staff was wearing on head. Residents were present after a Resident Council meeting ended in the dining room. An observation on 11/14/23 at 10:55 AM showed [NAME] D returned to kitchen in Bldg E, spoke in Spanish, tapped the left side of the pink headset. After she pressed the left side of the headset, AD provided an alternate meal order for an anonymous resident. An observation on 11/14/23 at 11:16 AM showed [NAME] F sitting at kitchen opening in Bldg G, on a stool, looking at cell phone and eating orange…
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 · E2023-11-16 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 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 interviews and record reviews, the facility failed to complete a MDS assessment every 92 day or within a timely manner for 3 (Residents #12, #18, and #37) of 12 residents reviewed for MDS assessments The facility failed to initiate a MDS assessment or complete an MDS assessment within 14 days after the ARD date for Residents #12, #18 and #37. This failure can place residents at risk of proper needs not being met, quality of care, assistive devices, and accuracy of assistance needed with activities of daily living. Findings included: Record review of Resident #12's face sheet, dated 11/15/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included Polyosteoarthritis (multi joint disease), hyperkalemia (high potassium levels in the blood), major depressive disorder, and chronic kidney disease. Review of Resident #12's MDS assessment, dated 5/15/23, showed a completion date of 5/31/23 (more than 14 days) and a MDS assessment dated [DATE] showed a completion date 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 · E2023-11-16 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on , interviews, and record reviews, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 7 (Residents #1, #3, #11, #12, #18, #25, and #37) of 12 residents reviewed for care plans. Residents #1, #3, #11, #12, #18, #25, and #37 did not have a comprehensive care plan completed 7 days after a comprehensive assessment. This failure places residents at risk for substandard quality of care, accuracy of needs, and assistance with activities of daily living. Findings included: Record review of Resident #1's face sheet, dated 11/16/23, revealed an [AGE] year-old female who was admitted to the facility originally on 2/17/2020 and readmitted [DATE]. Diagnoses included Dementia, major depressive disorder, type 2 diabetes, and epilepsy. Record review of Resident #1's MDS assessments revealed completion dates of 3/9/23, 6/4/23, and 8/27/23. MDS assessment dated [DATE] corresponded with a care plan completed on 3/20/23. MDS assessment dated [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-16 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 4 (Prairie House medication room, Cottonwood House medication room, Cottonwood House medication cart, and Sunset House medication room) of 6 medication storage areas reviewed for medication storage. The Prairie House Household Medication room refrigerator had medications that had been stored out of recommended storage temperatures. The Cottonwood Household Medication room refrigerator had medications that had been stored out of recommended storage temperatures. The Sunset Household Medication room refrigerator had medications that had been stored out of recommended storage temperatures. The Cottonwood Household Medication cart contained 3 insulin pens that had no medication labels. The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could result in a resident receiving the incorrect medication or a medication that would be ineffective for their…
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 · D2023-11-16 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 significant change of condition assessment within 14 days of determining or should have determined that there had been a significant changed in a resident physical or mental condition for 1 (Resident #13) of 12 residents review for significant changes of condition. The facility failed to complete a significant change of condition MDS assessment when Resident #13 was admitted to hospice. This failure to ensure comprehensive and accurate assessments are completed could affect residents by placing them at risk for not receiving correct care and services leading to deterioration in their condition. Finding include: Record review of Resident #13's face sheet dated 11-14-2023 revealed she was an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Parkinson's (a disorder of the central nervous system that affects movements to include tremors), dementia (a group of thinking and social symptoms that interferes…
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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in TX
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. 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 45F603. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-05, 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.