The Renaissance At Kessler Park
2428 Bahama Drive, Dallas, TX 75211 · For profit - Corporation · 135 certified beds · (214) 948-3811 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $11,031 in federal fines (most recent 2024-07-25)
- its payroll-based staffing rating is low (1/5)
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 | 15.2% | 15.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 5.1% | 3.0% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.4% | 2.4% | 6.5% | better 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 | 2.6% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.6% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 8.9% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.4% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 6.3% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.6% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 5.2% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 17.4% | 88.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.4% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.1% | 12.3% | 12.0% | typical |
‡ 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: 75.0% 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 32 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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 number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 75.0% | 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 | 71.9% | 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 | 68.8% | 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 | 43.4% | 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 — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 | 1.9% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 135 beds and averages 72.4 residents a day — about 54% occupied, or roughly 63 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.92 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.64 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 2.88 hrs/resident/day on weekends vs 2.94 on weekdays — 2% thinner on weekends. RN hours go from 0.16 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · Kcited before2024-07-25 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of two residents reviewed for quality of care. The facility failed to call physician for an x-ray order of Resident #1's left wrist and hand in a timely manner, which resulted in delayed treatment for a period of 7 days without treatment. On 06/15/2024, approximately 7:45 AM CNA B reported to RN A, pain and swelling in Resident # 1's left hand. Left hand noted swollen. Resident # 1 revealed difficult to move at wrist, there was swelling and slight reddish bruising. Resident stated she fell on 6/14/24 after breakfast. Resident #1 was able to get herself up. Resident #1 assessed by RN A, DON notified. X-ray order was received from the APN to x-ray left wrist and hand on 06/15/2024 approximately at 7:45 AM. On 06/15/2024 at approximately 6:00 PM, Resident #1…
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 before2026-05-12 · 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 safety in 1 of 1 (Kitchen #1) reviewed for food safety in facility's only kitchen. The facility failed to ensure leftover food was labeled, dated, and stored properly in the refrigerator.The facility failed to ensure personal cups were kept in the designated area and not on the prep table. These failures place residents at risk of cross-contamination and foodborne illnesses.Findings included:During an observation on 05/12/26 at 7:30 AM, of the prep table, reflected meatloaf on a plate covered with saran wrap next to a disposable cup containing water and ice. During an interview on 05/12/26 at 8:50 AM, Dietary Aide A stated the plate on the table contained meatloaf. She stated the plate should have been thrown in the trash, but it was on the prep table all night. Dietary A stated staff were not allowed to work overtime, and she was not able to load any more dishes after 7:15 PM, to wash them after the previous night'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 · D2026-05-12 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 3 residents reviewed for discharge or transfer.The facility failed to provide written notification to Resident #1's RP and Long-term care Ombudsmen. This failure could place residents at risk of improper transfer from the facility.Findings included:Findings included:Record review of Resident #1's face sheet, 05/12/26, reflected an [AGE] year old male, admitted [DATE], diagnosed with Schizophrenia, unspecified, (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations ,delusions and disorganized thinking), Unspecified Dementia, moderate with other behavioral disturbance (progressive decline…
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 · D2026-05-12 · 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 interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), 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. for 1(Resident #1) of 3 residents reviewed.The facility failed to update Resident #1's care plan to reflect a history of exit seeking behaviors.This failure could place residents at risk of not receiving proper care.Findings included:Record review of Resident #1's face sheet, 05/12/26, reflected an [AGE] year old male, admitted [DATE], diagnosed with Schizophrenia, unspecified, (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations ,delusions and disorganized thinking), Unspecified Dementia, moderate with other behavioral disturbance (progressive decline in…
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 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 dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #10) of 4 residents reviewed for pharmaceutical services. The facility failed to ensure a package of Resident #10's Morphine Sulfate and MS Contin were immediately delivered to facility nursing staff by CNA A. This failure placed all 60 residents at the facility at risk of not receiving the therapy and/or care per provider orders to allow her to attain or maintain her highest practicable physical, mental, and psychosocial well-being.Findings included: Record review of Resident #10's Face Sheet revealed she was an [AGE] year-old resident admitted to the facility on [DATE] for long term care. Relevant diagnoses included end stage heart disease (irreversible condition where the heart cannot pump effectively to meet the body's needs,) dementia (decline in…
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 before2025-06-18 · 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 two (Resident #1 and Resident #2) of four residents reviewed for infection control. 1.LVN B, LVN D, and CNA A did not wear gowns for PPE for Resident #1 who was on EBP during incontinent care and linen change. 2. The facility did not keep Resident #1 and Resident #2 ' s feeding pump pole free of a brown, thick substance, and a sticky dirt substance on both the poles, and the floor under the poles, while using the poles to feed Resident #1 and Resident #2. These failures affected residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings included: Resident#1 Review of Resident #1 ' s face sheet, dated 06/18/25, reflected she was a [AGE] year-old woman, admitted…
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 before2025-06-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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, interviews, and record review, the facility failed to provide a resident who was unable to carry out ADLs the necessary services to maintain grooming, and personal hygiene for one (Resident #1) of four residents reviewed for ADL care. Resident #1 ' s brief was soiled, and her bedding had a brown ring around her, with a strong ammonia odor, on 06/18/2025. This failure could affect residents by decreasing quality of life and contributing to skin breakdown. Findings included: Review of Resident #1 ' s face sheet, dated 06/18/25, reflected she was a [AGE] year-old woman, admitted on [DATE], with diagnoses of sepsis (the body responds to an infection by attacking the body ' s own organs), pneumonia (a lung infection), a pressure ulcer, dysphagia (an inability to swallow properly), stroke, and gastronomy status (use of a feeding tube inserted into the stomach). Review of Resident #1 ' s MDS assessment, dated 03/25/25, reflected Resident #1 had unclear speech, impaired vision, was rarely able 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 · Dcited before2025-06-18 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 receiving enteral feeding received appropriate care and services to prevent complications of enteral feedings for one (Resident # 1) of two residents reviewed for enteral feedings. 1.The facility failed to ensure Resident #1 was not laid flat in bed while her enteral feeding was still running. This failure placed residents with enteral feedings at risk of aspiration (entering the airways or lungs) and hospitalization. Findings Included: Review of Resident #1 ' s face sheet, dated 06/18/25, reflected she was a [AGE] year-old woman, admitted on [DATE], with diagnoses of sepsis (the body responds to an infection by attacking the body ' s own organs), pneumonia (a lung infection), a pressure ulcer, dysphagia (an inability to swallow properly), stroke, and gastronomy status (use of a feeding tube inserted into the stomach). Review of Resident #1 ' s MDS assessment, dated 03/25/25, reflected Resident #1 had unclear speech,…
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 · D2025-01-24 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to ensure each resident had the right to be free from abuse for four (Residents #1, #2, #3, #4) of 9 residents reviewed for Abuse. 1.The facility staff failed to ensure Resident #1 did not hit Resident #2, which resulted in Resident #2 getting a skin tear to his face in the dining room on 09/14/24. 2. The facility staff failed to ensure Residents #3 did not throw orange juice twice, at Resident #4, which resulted in Resident #4 hitting Resident #3 in the face and causing redness to Resident #3's face, in the dining room on 09/13/24. These failures could place residents at risk of injuries such as fractures, bruising, skin tears, and psychological harm resulting in decreased health and psycho-social well-being. Findings included: 1. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a BIMS score of 14 (No cognitive impairment), with medically complex…
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 before2024-08-29 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen reviewed for food safety. The facility failed to use one utensil for each food item served during lunch. This failure could place residents at risk for food-borne illness and food contamination. Findings include: Observation on 08/28/2024 at 11:55 AM revealed [NAME] D used the same tongs to pick up and serve both pork loin and beef patties. [NAME] D repeated the serving actions again at 11:58 AM Observation on 08/28/2024 at 12:08 PM reflected [NAME] D used the tongs previously used to pick up pork loin and beef patties to pick up French fries. Interview on 08/28/2024 at 12:21 pm with [NAME] D revealed there was only one pair of tongs to use during lunch service. [NAME] D stated the risk of using one utensil to serve multiple food items would be food transfer. Interview on 08/28/2024 at 1:18 PM with Dietary Manager reflected each food item was supposed to have its own serving utensil. He stated that there…
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 · D2024-08-29 · 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 ensure, in accordance with accepted professional standards and practices, the medical record was maintained on each resident that were complete and accurately documented for 1 (Resident #49) of 8 residents records reviewed for treatment documentation. The facility failed to ensure Resident #49's orders for his tracheostomy and tracheostomy care were in the EMR. This failure could affect any resident, placing them at risk of inaccurate information and resulting inappropriate care. Findings included: Review of Resident #49's admission Record, dated 08/29/24, reflected he was a [AGE] year-old male originally admitted on [DATE], and most recently re-admitted on [DATE], with diagnoses of anoxic brain damage (brain damage from lack of oxygen), tracheostomy status (surgically inserted tube into airway for breathing), and acute and chronic respiratory failure with hypoxia (a condition in which the lungs do not properly exchange oxygen for carbon…
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 17 citations
- Potential for harm · F2024-07-25 · tag F0837 — widespreadEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, the facility failed to ensure a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and the governing body appoints the administrator who is licensed by the State, where licensing is required for one (Administrator) of one staff reviewed for administrative license. The facility failed to ensure the Administrator's license was current, which expired [DATE]. This deficient practice could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents. Findings included: Internet search of, https://txhhs.my.site.com/TULIP/s/public-search, revealed the Administrator's license was issued on [DATE] and expired [DATE].
- Potential for harm · D2024-07-25 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 1 of 63 resident (Resident #1) reviewed for neglect, in that: The facility failed to report the allegation of neglect r/t falls for Resident #1 to the State Agency within required reporting timeframes. This failure placed residents at risk of ongoing neglect. Findings included: Record review of Resident #1's face sheet dated 07/09/2024 revealed a [AGE] year-old female admitted to the facility on 04/25/2001 and readmitted on [DATE] with a diagnoses of Multiple Fractures of Ribs,…
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 · D2024-05-08 · 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 a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, and the comprehensive person-centered care plan for 1 of 3 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's oxygen tubing was dated. These failures affected residents and placed them at risk of not receiving the needed services for respiratory care. Findings include: Record review of Resident #1's face sheet, revealed an [AGE] year-old female was admitted on [DATE] with a primary diagnoses of DEMENTIA,WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE; CHRONIC RESPIRATORY FAILURE (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), Record review of Resident # 1's Medication Administration Record, dated May 2024…
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 · D2024-03-04 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to allow the resident representative the right to exercise the resident's rights to the extent those rights were delegated to the representative for 1 of 1 resident (Resident #1) reviewed for resident rights. The facility failed to provide Resident #1's medical records, when Resident #1's POA requested them on 02/07/24. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions. The findings included: A record review of Resident #1's electronic Facesheet, dated 02/21/24, indicated Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses which included pressure ulcer of sacral region, other chronic pain, non-pressure chronic ulcer, arthritis, muscle weakness, lack of coordination, and repeated falls. A record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 10, which indicated his cognition was moderately…
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 before2024-01-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for one (South hall) of two halls reviewed for environment affecting 24 of 66 rooms. The facility failed to ensure the physical layout maximized resident independence and did not pose a safety risk on 2 of the 3 sections of the South hall which affected 24 of 66 rooms. This deficient practice could place residents at risk for falls and/or injury. Findings included: An observation on 01/17/24 at 9:18 AM on the South hall revealed a bed frame and mattress against the wall in between the entrance to rooms [ROOM NUMBERS]. At 9:20 AM a Hoyer lift (assistive device used to transfer residents between a bed and chair) was against the wall outside of room [ROOM NUMBER]. An extra bed frame was against the wall between rooms [ROOM NUMBERS]. At 9:21 AM an unlocked wheelchair was noted outside of room [ROOM…
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 before2024-01-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the resident's choices for 1 of 4 residents (Resident # 2) reviewed for quality of care. The facility failed to follow physician orders concerning a non-pressure wound of the left, lower medial (situated in the middle) buttock for Resident # 2. This failure could place residents at risk of delayed treatment of injuries, worsening of injuries, pain and infection. Findings Included: Record review of Resident # 2's admission Record dated 1/18/24 revealed, a [AGE] year-old male who admitted to the facility on [DATE] and had diagnoses which included stage 3 pressure ulcer of the sacral (located at the base of the spine) region, chronic pain, and non-pressure chronic ulcer of skin of other sites with unspecified severity. Record review of Resident # 2'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 · D2024-01-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 15 residents (Resident # 3 and Resident # 4) reviewed for wounds. The facility failed to ensure treatment and documentation of pressure ulcers for Resident # 3 and # 4 and failed to ensure orders from the hospital were correct and accurate for Resident # 4's pressure ulcers upon readmission. This failure could affect the residents, who received pressure ulcer care, by placing them at risk of unnecessary infection and worsening of pressure ulcers. Findings included: 1. Record review of Resident # 3's admission Record dated 1/18/24 revealed, a [AGE] year-old male who admitted to the facility on [DATE] and had diagnoses of major depressive disorder, stage 4 pressure ulcer of sacral (located at the base of the spine) region,…
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 · E2023-12-14 · 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 incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for 1 of 7 residents (Resident #2) reviewed for PASRR. The facility failed to submit NFSS forms timely for Resident #2. This failure could place residents at risk for not receiving specialized services in a timely manner. Findings included: Record review of Resident #2's admission record, dated 12/14/2023, revealed a [AGE] year-old female who admitted on [DATE] with diagnoses that included traumatic brain injury, dysarthria (difficulty speaking) and anarthria (loss of speech), and hemiplegia (one sided muscle paralysis or weakness) affecting left nondominant side. Record review of Resident #2's Quarterly MDS assessment, dated 11/07/2023, reflected a BIMS score of 9, indicating moderative cognitive impairment. The MDS indicated Resident #2 was usually understood and usually understood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-14 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
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 all PASRR level I residents were provided with an accurate PASRR level I for 2 of 7 (Resident #3 and Resident #4) reviewed for PASRR screening. The facility failed to complete PASRR level 1 screenings for Resident #3 and Resident #4. This failure could place residents at risk of not being evaluated and not receiving specialized services to meet their needs. Findings included: Record review of Resident #3's admission record, dated 12/14/2023, revealed a [AGE] year-old male with an original admission date of 04/23/2001, who readmitted on [DATE] with diagnoses that included unspecified intellectual disabilities, epilepsy, and major depressive disorder. Record review of Resident #3's quarterly MDS assessment, dated 09/01/2023, revealed Resident #3 was rarely understood and rarely understood others. Further review of the MDS revealed the BIMS score to be blank and Resident #3 was severely impaired in cognitive skills for daily decision making. Record…
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 before2023-12-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 are unable to carry out the activities of daily living received the necessary services to maintain personal hygiene for 1 of 6 residents (Resident #1) reviewed for ADL care. The facility failed to ensure Resident #1 received timely incontinent care. This failure could put residents at risk of impaired skin integrity and a decreased quality of life. Findings included: Record review of Resident #1's admission record, dated 12/15/2023, revealed a [AGE] year-old-male who admitted to the facility on [DATE] with diagnoses that included pressure ulcer of sacral region stage 3, non-pressure chronic ulcers on right and left lower leg, muscle weakness, and Covid-19. Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 9, indicating moderate cognitive impairment. Section G, of the OSA (Optional State Assessment) MDS, dated [DATE], reflected Resident #1 required extensive 2 person assist with bed…
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 before2023-09-22 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 received nutrition by enteral means received the appropriate treatment and services according to professional standards of maintenance for one (Resident #1) of two residents reviewed for enteral feeding. The facility failed to ensure Resident #1's g-tube syringe (used for flushing a continuous feed g-tube with water before, after, and during medication administration via the g-tube) was exchanged daily for a new syringe. This failure could affect residents by causing infection. Findings included: Review of Resident #1's face sheet, dated 09/22/23, reflected she was a [AGE] year-old woman, admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis) affecting both sides of her body, stroke history, dysphagia (trouble swallowing), and gastronomy (g-tube or feeding tube) status. Review of Resident #1's MDS assessment, dated 07/06/23, reflected Resident #1 did not have speech, but was usually…
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 before2023-09-22 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 one (Resident #2) of seven residents observed for infection control. CNA C failed to properly execute glove changes and hand hygiene when entering the room of Resident #2, who was on contact isolation for an infection. This failure could place residents at risk for spread of infection. Findings included: Review of Resident #2's face sheet, dated 09/22/23, reflected the resident was an [AGE] year-old woman, admitted on [DATE] with diagnoses which included an infection in her vertebra, diabetes, congestive heart failure and chronic kidney disease. Review of Resident #2's orders reflected an order dated 09/21/23 for contact isolation. Review of Resident #2's progress note, dated 09/21/23, reflected a care plan meeting with 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 · E2023-06-15 · tag F0553 — failed to let residents help plan their care — patternAllow 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 observation, interview and record review, the facility failed to ensure the resident and/or representative had the right to participate in the development and implementation of his or her person-centered plan of care for 4 (Residents #24, #35, #40, and #70) of 10 resident records reviewed for initial care plan meetings and quarterly care plan meetings. Findings included: Review of Resident #24's MDS dated [DATE] revealed resident admitted to facility on 05/18/2023 with a diagnosis of Seizure Disorders; Syncope and Collapse; Multi-Resistant Drug; Diabetes Mellitus. Review of Resident #35's MDS dated [DATE] revealed resident admitted to facility on 07/02/2021 with a diagnosis of Anemia; Coronary Artery Disease; Hypertension; Diabetes Mellitus; Deep Vein Thrombosis. Review of Resident #40's MDS dated [DATE] revealed resident admitted to facility on 09/06/2020 with a DX of Anemia; Deep Vein Thrombosis; Heart Failure; Hypertension; Cirrhosis. Review of Resident #70's MDS dated [DATE] revealed 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 · E2023-06-15 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of 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 observation and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 5 (Residents #2, #52, #10, #16, #22) of 18 residents reviewed for available call systems in 200 South Hall. Staff failed to ensure Resident #2, #52, #10, #16, #22's call cords were within reach. This failure could affect residents who resided on Unit 200 Hall, by placing them at risk for decreased quality of life and a delay in receiving care. Findings included: Review of Resident #2's Minimum Data Set, dated [DATE] reflected a [AGE] year-old male readmitted to facility on 05/01/2023 with a diagnoses of Alzheimer's Disease; and Hypertension; Renal Insufficiency; Aphasia, Seizure Disorder; and Quadriplegia. The Minimum Data Set revealed extensive assistance with ADLS and limited range of motion on one side and a risk for falls. Resident #2 had Dementia and an intellectual disability. Resident #2 is totally dependent on…
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 before2023-06-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that residents had the right to a clean, comfortable, and homelike environment, for South Hall 200. The facility failed to properly maintain areas in a clean, comfortable, and sanitized environment on South Hall 200 for 14 residents rooms out of 28 resident rooms (Rooms 207, 209, 210, 211, 221, 225, 226, 227, 228, 229, 230, 231, 232, 233). Findings included: Observations on 06/13/2023 between 10:00 AM to 10:30 AM, revealed build-up of heavy dirt at the entrance of each doorway of Rooms 207, 209, 210, 211, 221, 225, 226, 227, 228, 229, 230, 231, 232, 233. The floors in the rooms revealed stains on floors and dirt build up around baseboards. Observation of room [ROOM NUMBER]A on 06/13/2023 at 10:15 AM, the floor in area of Resident #2's tube feeding were hanging, the floor has drippings on the floor from the feeding. Interview with Resident #25 and Resident #13 on 06/15/2023 at 8:50 AM from room [ROOM NUMBER] revealed that 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 · E2023-06-15 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week for 18 (03/11/23, 03/12/23, 03/18/23, 03/19/23, 03/25/23, 03/26/23, 04/01/23, 04/02/23, 04/08/23, 04/09/23, 04/15/23, 04/16/23, 04/22/23, 04/23/23, 05/06/23, 05/07/23, 05/21/23 and 06/04/23) of 28 days reviewed for nursing services. The facility failed to have RN coverage for eight consecutive hours for 18 days (Saturdays and Sundays) beginning 03/10/23 until 06/13/23. This failure could place residents at risk for missed resident nursing assessments, interventions, care, and treatment. Findings included: Record review of timecards for RN B, for the time-period of 03/10/23 to 06/13/23 revealed there was not eight consecutive hours of RN coverage for 18 out of 28 days (03/11/23, 03/12/23, 03/18/23, 03/19/23, 03/25/23, 03/26/23, 04/01/23, 04/02/23, 04/08/23, 04/09/23, 04/15/23, 04/16/23, 04/22/23, 04/23/23, 05/06/23, 05/07/23, 05/21/23 and 06/04/23) reviewed for weekend RN coverage on Saturdays and Sundays. Record review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-15 · 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, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one staff (MA A) of three staff observed during medication pass for infection control in that: 1. MA A failed to sanitize the B/P cuff and machine between residents. This failure could affect all residents by causing cross contamination and placing them at risk for exposure to a contagious disease, infection, and possible hospitalization. An observation on 06/14/23 at 8:51 AM, revealed MA A greeted Resident #42, let her know what she was going to do. MA A washed her hands, took her B/P cuff/machine from the top of her cart, without sanitizing it, went into Resident #42's room and placed the B/P cuff on Resident #42's right wrist ad obtained Resident #42's B/P and pulse MA A went back to her medication cart, placed the B/P cuff on top of it. She used sanitizer on her hands, prepared…
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
$11,031 in federal fines across 1 penalty.
- $11,031 — penalty dated 2024-07-25
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 ADVANCED HEALTHCARE SOLUTIONS — 28 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.9 | +0.1 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 1 of 5 | 2.0 | -1.0 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 27 homes this chain runs (chain average 2.9★, per CMS)
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 |
|---|---|---|---|
| HOOPER, GRADY | Individual | CORPORATE DIRECTOR | since 04/01/2023 |
| SILBERSTEIN, ARI | Individual | CORPORATE DIRECTOR | since 01/01/2023 |
| KESSLER PARK SNF, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2023 |
| MITCHELL, MONTE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/13/2024 |
| PRASAD, JYOTSNA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/13/2024 |
CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 94% 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. This home reported $60K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 455996. 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.