Val Verde Nursing And Rehabilitation Center
100 Hermann Dr, Del Rio, TX 78840 · Government - Hospital district · 76 certified beds · (830) 775-7477 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $138,908 in federal fines (most recent 2023-10-01)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 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 | 21.2% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.2% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 2.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 5.4% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 8.2% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.5% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 11.8% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.9% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.6% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 92.9% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 34.7% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 16.7% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.76 | 2.17 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.05 | 2.06 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
41.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 36.4% 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 22 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 0.21 therapist hours per resident per day in 2025Q4 — more than 25% of the 13,714 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 24% 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 14% — 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 | 41.4%CMS range 30.8–54.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 5.8–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 36.4% | 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 | 36.4% | 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 | 40.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — 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 | 2.9% | 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 | 7.5%CMS range 4.3–12.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.15 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 76 beds and averages 51.4 residents a day — about 68% occupied, or roughly 25 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 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 2.66 hrs/resident/day on weekends vs 3.14 on weekdays — 15% thinner on weekends. RN hours go from 0.44 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% is below 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 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.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · K2023-10-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide 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 the comprehensive assessment of a resident, the facility failed to ensure that 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 1 of 6 residents (Resident #1) reviewed for pressure sores, in that: The facility failed to ensure Resident #1 received wound care and treatment as ordered by a physician. -Resident #1's right great toe was not monitored daily for changes once per day as ordered by a physician. -Resident #1's right heel was not monitored daily for changes once per day as ordered by a physician. -Resident #1's skin tear to the left upper leg was not monitored every shift for signs of infection as ordered by a physician. -Resident #1's pressure ulcer to her left buttock was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician. -Resident #1's pressure ulcer to her right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-08-12 · tag F0680 — patternEnsure the activities program is directed by a qualified professional.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the State for 1 of 1 facility reviewed for qualifications of activity professionals. The facility failed to have a qualified Activities Professional direct their activities program. This deficient practice could place residents at risk of not receiving approaches that were individualized to match the skills, abilities, and interests/preferences of each resident for activities. The findings included: During an interview on 08/11/2026 at 5:50 p.m., the Activity Director revealed that she has not obtained her certification as an activity director, but she started her online training as of February 2026. She stated that she has completed 8 of 12 modules of online training and the Administrator oversees her coursework and provides guidance in activities for the NF. She stated that she is unable to obtain an online transcript of her activity…
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 before2026-08-12 · 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 2 (Resident #20, Resident #23) of 3 residents reviewed for infection control in that:1.The facility failed to ensure CNA C performed hand hygiene before applying clean gloves while providing incontinence care to Resident #20.2. LVN E did not change gloves from clean to dirty during ostomy care for Resident #23.This failure could lead to infection or illness. Findings included: 1.Record review of Resident #20's admission Record dated 08/12/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Relevant diagnoses included: hemiplegia and hemiparesis following cerebral infarction (when a blocked artery or blood clot stops blood and oxygen from reaching part of the brain, resulting 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 · Dcited before2026-08-12 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 3 of 8 (Resident #3, Resident #40 and Resident #56) residents whose records were reviewed for assessments. Nursing staff failed to code Resident #3 had musculoskeletal Other Fracture, exhibited behavioral symptoms, including physical behavioral symptoms toward others, and inaccurately documented active diagnoses on his MDS assessment.Nursing staff failed to code Resident #40 had falls, frequency of falls, and falls with no injury and with injury on her MDS assessment. Nursing staff failed to code Resident #56 had falls and musculoskeletal other fracture on her MDS assessment. These failures could place residents at risk of not identifying care areas and result in residents not receiving needed care and services.The findings included: 1. Record review of Resident #3's admission Record, dated 08/11/2026 revealed a [AGE] year-old male admitted on [DATE] and re-admitted 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 · D2026-08-12 · tag F0644 — isolatedCoordinate 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 PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. for 1 of 3 (Resident #57) PASRR resident in that:Resident #57's PASRR II recommendations for a customized manual wheelchair (10/10/2025) and Occupational Therapy (8/4/2025)/Physical Therapy (7/28/2025) NFSS was submitted after 20 days. This could affect all residents on PASRR services and could result in residents on PASRR services not provided with DME or specialized services. The Findings:1.Record review of Resident 57's admission Record dated 8/9/2026 documented she was admitted on [DATE] and was discharged to the community on 3/3/2026. Resident #57 had a diagnosis is of Spina Bifida (a neural tube birth defect where the spinal column fails to close completely during the first month of pregnancy) with Hydrocephalus) (the abnormal buildup of cerebrospinal fluid in the brain'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 · D2026-08-12 · tag F0645 — isolatedPASARR 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 observation, interview and record review, the facility failed to ensure preadmissions screening for individuals with a mental disorder and individuals with intellectual disability for 1 of 6 (Resident #3) residents reviewed for PASARR accuracy. The MDS Nurse failed to accurately screen Resident #3 for mental illness upon admission to the facility. This failure could place the residents at risk of not receiving the necessary care and services.The findings included: Record review of Resident #3's admission Record, dated 08/11/2026 revealed a [AGE] year-old male admitted [DATE] and re-admitted [DATE]. Resident #3 was not listed as his own responsible party. Record review of Resident #3's Medical Diagnoses, undated and accessed 08/11/2026 at 5:15 p.m., revealed diagnoses including other specified fracture of unspecified pubis, subsequent encounter for fracture with routine healing (pelvic injury) being listed as principal diagnosis, major depressive disorder (mood disorder that causes a persistent feeling…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-08-12 · 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 and 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 2 of 8 (Resident, #3 and Resident #25) residents in that:Resident #25 was not care planned for his full code status. Nursing staff failed review and revise Resident # 3's comprehensive person-centered care plan following recent behaviors prompting psychiatric assessment on 7/23/2026 that documented Resident #3 as unstable and direction to Employ use of redirection at this time. This failure could affect all residents and could result in residents not having their wants and needs identified and met. The Findings: 1. Record review of Resident #25's admission Record dated 8/12/2026 documented he was admitted on [DATE] with diagnoses of complete traumatic…
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 · D2026-08-12 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide activities based on the comprehensive assessment and care plan, designed to meet the interests of and support the physical, mental and psychosocial well-being of 2 of 8 (Resident #40 and Resident #56) residents who were reviewed for activities. The facility failed to consistently provide individualized activities and did not meet the needs of Resident #40 and Resident #56 on a weekly basis. This failure placed the residents at risk of becoming apathetic (marked indifference to the environment), isolated from others, having a depressed mood, boredom, loneliness, and a decreased quality of life. The findings included: 1. Record review of Resident #40's admission Record, dated 08/12/2026, revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident #40 was not listed as her own responsible party. Record review Resident #40's Medical Diagnoses, undated and accessed 08/12/2026 at 3:34 p.m., revealed diagnoses…
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 · D2026-08-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure a resident who was incontinent with bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #58) of 1 resident reviewed for catheter care. The facility failed to ensure Resident #58 had a leg strap to secure her indwelling urinary catheter tubing. This deficient practice could place residents at risk of complications and infection from movement at the insertion site. The findings included: Record review of Resident #58's admission Record dated 08/11/2026 reflected an [AGE] year-old female newly admitted on [DATE] with diagnoses of secondary malignant neoplasm (cancer that has spread from its original site to another area of the body), fracture of superior rim of left pubis (a break in the upper bone at the front of the pelvis), and dementia (loss of memory, language, problem-solving and other thinking abilities). Record review for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-08-12 · 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, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #35) of 7 residents reviewed for medication administration in that:The facility failed to accurately transcribe a physician-ordered medication onto Resident #35's Medication Administration Record. As a result, the medication was reflected on the MAR with an incorrect route of administration. This failure could place residents at risk of injury due to incorrect medication administration and inaccurate orders.Findings included: Record review of Resident #35's admission Record dated 08/11/2026, revealed the resident was an [AGE] year-old male, admitted to the facility on [DATE], with diagnoses of cerebral infarction (when a blocked artery or blood clot stops blood and oxygen from reaching part of the brain), dysphagia oropharyngeal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-03 · 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 observation, interview, and record review, the facility failed to ensure all alleged violations involving mistreatment, neglect, abuse or misappropriation of resident property were reported immediately, but not later than 2 hours if the alleged violation involved abuse or resulted in serious bodily injury, to other officials (including to the State Agency) for one (1) of five (5) residents (Resident #1) reviewed for abuse. The ADMIN, who is the Abuse Coordinator, failed to immediately report (within 2 hours) an allegation of abuse made by Resident #1's family member on 01/21/2026 to HHSC. The failure could affect 46 residents and could result in undetected abuse and/or decline in feelings of safety and well-being.The findings included: Record review of Resident #1's admission Record, dated 02/03/2026, revealed a [AGE] year-old female admitted on [DATE]. Under Contacts, Resident #1 was listed as Self and Resident #1's family member was noted as [NAME] to Responsible Party and Emergency Contact #1. 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.
Show the remaining 18 citations
- Potential for harm · Ecited before2025-12-03 · tag F0609 — failed to report abuse allegations — patternTimely 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 interviews and record review, the facility failed to ensure 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, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedure. In response to allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source for 2 of 10 residents (Resident #1 and Resident #2) reviewed for reporting allegations of abuse and neglect. The DON failed to identify an un-witnessed fall as an alleged violation of injury of unknown source for 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 · E2025-12-03 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to have evidence all allegations of abuse, neglect, or mistreatment were thoroughly investigated and documented for 2 of 10 residents (Resident #1 and Resident #2) reviewed for a fall injury. The facility failed to have evidence that a thorough investigation was conducted following the allegation Resident #1 had an unwitnessed fall with injury on 10/07/2025 and Resident #2 had an unwitnessed fall with injury on 11/12/2025. These failures could place residents at risk for abuse and neglect by not investigating injuries of unknown origin. The findings included: Review of Resident #1's admission record dated 12/03/2025 reflected he was admitted to the facility on [DATE], readmitted on [DATE], and discharged on 11/18/2025. His diagnoses included acute respiratory failure with hypoxia (a condition when the respiratory system fails to maintain adequate oxygen levels in the blood), dementia (a condition characterized by a decline in cognitive function), muscle…
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 before2025-06-06 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for, 1 of 4 medication carts observed, in that: The Nurse Medication Cart in the 300 hall contained five loose medication pills. This failure could place residents who receive medications at risk for not receiving the intended therapeutic effects of medications. The findings were: Observation on 06/05/2025 at 10:18 a.m. of the 300 Hall Nurse Medication Cart revealed there were five loose medication pills inside one of the drawers. During an interview with LVN (B) on 06/05/2025 at 10:25 a.m., LVN(B) confirmed there were five loose medication pills inside a drawer of the Nurse Medication Cart. She stated the pills must have dropped at some point during her medication pass this morning, or perhaps another nurse at an undetermined time. During an interview with the DON on 06/05/2025 at 10:30 a.m., she stated medication carts should not have loose medications. They were the responsibility of the nurse who…
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 · E2025-06-06 · tag F0801 — patternEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements. The Food Service Director did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. Findings included: During an interview on 6/5/25 at 9:50am, the Food Service Director was hired 03/10/25. She stated she was not a certified dietary manager or certified food service manager, and she did not have an associate's or higher degree in food service management or in hospitality. The Food Service Director stated she previously…
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 · E2025-06-06 · 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 facility in that: 1. The facility failed to clean an overhead ceiling vent in the main kitchen area. 2. The facility failed to close an attic trap door on the outside kitchen patio area. 3. The facility failed to paint over a peeling ceiling area located over the dish machine conveyor line. These failures could place residents at risk for food borne illness. The findings included: Observation on 06/03/2025 from 9:05am until 9:40am with the Food Service Director revealed the following: a. There was a 4x1.5 foot overhead ceiling vent in the main kitchen area that was covered with dirt and dust particles. b. There was an attic ceiling trap door that was not fully closed above the outside kitchen patio area where two food storage freezers used by kitchen staff were located c. In the dish room above the dish machine conveyor belt that was an area on the ceiling that measured approximately 1 foot…
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 · D2025-06-06 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #37) reviewed for privacy, in that: MA (A) did not lock the computer after she walked away and left it unattended, which exposed Resident #37's morning medication list. This failure could place residents at risk of having their medical information exposed to others and cause residents to feel uncomfortable and disrespected. The findings include: Record review of Resident #37's face sheet dated 6/04/25 reflected an [AGE] year-old female resident who was admitted to the facility on [DATE] with diagnoses which included: Heart Failure (condition in which the heart isn't pumping as well as it should), kidney disease ( means your kidneys are damaged and can't filter blood the way they should) and Peripheral vascular disease(disorder of the blood vessels that affects the legs and feet). 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 · Dcited before2025-06-06 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete assessments for 1 of 6 residents reviewed (Resident #20) for accuracy of assessments, in that: Resident #20's MDS assessment was inaccurate. This deficient practice could result in diminished quality of care due to inaccurate resident assessment. The findings were: Record review of Resident #20's face sheet, dated 06/06/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia, Cognitive Communication Deficit, and Chronic Obstructive Pulmonary Disease. Record review of Resident #20's Quarterly MDS, dated [DATE], revealed the resident was rarely or never understood, and Staff Assessment for Mental Status revealed the resident had both short-term and long-term memory problems. Further review revealed the MDS noted the resident was not receiving hospice services. Record review of Resident #20's Care Plan, revised 10/22/2024, revealed The resident has a terminal prognosis and is 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 · Dcited before2025-06-06 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records that were complete and accurate, in accordance with accepted professional standards and practices, for 1 of 6 residents (Resident #159) reviewed for complete and accurate medical records in that: Resident #159's diagnoses list was incomplete. This deficient practice could result in errors in care and treatment. The findings were: Record review of Resident #159's face sheet, dated 06/06/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Heart Failure, Pneumonia, and Muscle Wasting and Atrophy. Further review revealed Hypertension and Hypothyroidism were not included. Record review of Resident #159's clinical record as of 06/06/2025 revealed an admission MDS assessment was not yet due to be completed and therefore, the resident's BIMS score was unavailable. Further review of Resident #159's clinical record as of 06/06/2025 revealed the resident's comprehensive care plan was in process…
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 before2024-05-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, 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 2 of 16 residents (Resident #24, #46) reviewed for care plans, in that: 1. The facility failed to ensure wound care management was included on the Care Plan for Resident #24 when he developed pressure injury wounds on 4/17/2024. 2. The facility failed to ensure significant weight loss was included on the Care Plan for Resident #46 after she lost 7.14% of her body weight from 3/6/2024 to 4/8/2024. This failure could place residents at risk of not receiving the care needed to maintain their highest, most practicable, physical, social, and psychosocial level of well-being. The findings were: 1. Record review of the admission Record revealed Resident #24 was a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 were offered a therapeutic diet when there was a nutritional problem, and the health care provider orders a therapeutic diet for 1 of 8 Residents (Resident #46) reviewed for nutritional status in that: The facility failed to ensure Resident #46 was receiving the ordered therapeutic diet. These failures could place residents who are dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in quality of life. Findings included: Record review of Resident #46's Face Sheet, dated 5/10/2024, reflected a [AGE] year-old female resident initially admitted on [DATE] with diagnosis including pressure ulcer of sacral region, stage 4, and type 2 diabetes mellitus without complications. Record review of Resident #46's Quarterly MDS Assessment, dated 4/4/2024, reflected Resident #46 had a BIMS score of 9, indicating the resident was moderately impaired.…
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 before2024-05-10 · 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 all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (the Nurses Medication Cart) reviewed for medication storage, in that; The facility failed to ensure the Nurses Medication Cart was locked when it was left unattended in the common area of in front of the nurses' station. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings were: In an observation on 5/08/2024 at 12:21 PM the Nurse's Medication Cart was left unlocked and unattended in the common area in front of the nurse's station. The cart contained scissors, prescription and over the counter medications. There were staff, residents, and visitors in the immediate vicinity. In an interview on 5/08/2024 at 12:25 PM, LVN A stated the Nurses Medication Cart was her responsibility. LVN A stated the Nurses Medication Cart should not be left unlocked when not in use.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-17 · 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, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 resident (Residents #1) out of 8 residents reviewed for medication administration in that: The facility failed to ensure Resident #1 was administered medications according to physician parameters. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications, could result in a worsening or exacerbation of chronic medical conditions, hospitalization and or a diminished quality of life. The findings include: Record review of the admission Record revealed Resident #1 was a [AGE] year-old female, originally admitted to the facility on [DATE]. Record review of the comprehensive MDS assessment dated [DATE] revealed Resident #1's primary medical condition for admission was amputation 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 before2023-10-01 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 4 of 4 residents (Residents #1, 2, 3, 4) reviewed for quality of care 1. The facility failed to ensure Resident #1 received wound care and treatment as ordered by a physician. -Resident #1's right great toe was not monitored daily for changes once per day as ordered by a physician. -Resident #1's right heel was not monitored daily for changes once per day as ordered by a physician. -Resident #1's skin tear to the left upper leg was not monitored every shift for signs of infection as ordered by a physician. -Resident #1's pressure ulcer to her left buttock was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician. -Resident #1's pressure ulcer to her right buttock was not cleansed with wound…
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 before2023-10-01 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 interviews, and record reviews, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 3 of 4 residents (Resident #s 2,3,and 4) reviewed for resident records, in that: 1. The facility failed to accurately document Resident #s 2, 3, and 4's September 2023 wound treatments. 2. The facility failed to ensure Resident #3's physician progress notes from July 2023 and September 2023 were in the resident's electronic clinical record. This deficient practice could affect all residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: 1. Resident #2 Record review of Resident #2's a face sheet dated 9/30/2023 revealed Resident #2 was [AGE] years of age and was initially admitted on [DATE]. Resident #2's diagnoses included: type 2 diabetes, severe sepsis with septic shock, encounter for surgical aftercare following surgery on 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 · Dcited before2023-10-01 · 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 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 infection for 1 of 4 residents (Resident #2) reviewed for infection control LVN B failed to maintain a sterile environment when performing wound care for Resident #2 These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #2's a face sheet dated 9/30/2023 revealed Resident #2 was [AGE] years of age and was initially admitted on [DATE]. Resident #2's diagnoses included: type 2 diabetes, severe sepsis (infection in the blood stream) with septic shock, encounter for surgical aftercare following surgery on the digestive system, acquired absence of other specified parts of digestive tract, pressure ulcer of right heel stage 2 (onset…
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.
- No harm found · Ccited before2026-08-12 · tag F0732 — widespreadPost nurse staffing information every day.
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 ensure the Nurse Staffing Information. Data requirements. The facility must post the following information on a daily basis. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift and Resident census. Posting requirements. The facility must post the nurse staffing data of this section on a daily basis at the beginning of each shift. Data must be posted as follows: Clear and readable format. In a prominent place readily accessible to residents, staff, and visitors. Public access to posted nurse staffing data. Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater for 1 of 1 nursing home in that:The Nurse Staffing posting was not posted on the correct date, and for some nursing staffing posting the data of census and actual hours were missing. The Facility failed to ensure 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.
- No harm found · Ccited before2026-02-03 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to post on a daily basis information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 4 of 4 days (01/31/2026 - 02/03/2026) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information from 01/31/2026 to 02/03/2026. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census. The findings included: During an observation on 02/03/2026 at 10:14 a.m. and at 04:15 p.m., a document labeled [facility name] Direct Care Daily Staffing 8-Hour, dated 01/30/2026, was posted on a wall of the front lobby/ front dining space. The document included the following information: current census and the number and hours worked of registered nurses, licensed vocational…
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.
- No harm found · C2025-06-06 · tag F0912 — widespreadProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to provide the required 80 square feet per resident in 23 of 37 resident rooms (Rooms 7-8, 20-40) reviewed for bedroom mearsurement. The facility failed to ensure rooms measured the required 80 square feet per resident. This failure could impede the ability of residents living in these rooms to attain their highest practicable well-being. Record review of previous citation noted on the 2567 document dated 4/08/23 revealed an observation was made on 4/3/23 at 12:28 pm noting for rooms 7-8, 20-21, 24, 26-32, 34, 36, 39 (which had two beds) was calculated to be between 144-155 square feet resulting between 72 and 77.5 square feet per resident. Record review of the Provider History Profile which was updated on 2/2/23 revealed an existing room size waiver from the re-certification survey with an exit date of 4/08/23. Interview with the Administrator on 6/5/25 at 3:00pm who stated she wanted to provide a copy of a signed Form 3762-Room Size Waiver request form. The Administrator stated that the facility would be requesting that…
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
$138,908 in federal fines across 1 penalty.
- $138,908 — penalty dated 2023-10-01
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 WELLSENTIAL HEALTH — 67 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 | 2 of 5 | 2.7 | -0.7 vs chain |
| Health inspection | 2 of 5 | 2.9 | -0.9 vs chain |
| Staffing | 2 of 5 | 1.6 | +0.4 vs chain |
| Quality measures | 3 of 5 | 4.2 | -1.2 vs chain |
The other 66 homes this chain runs (chain average 2.7★, per CMS)
Showing 40 of 66; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| VAL VERDE COUNTY HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 04/01/2022 |
| REGENCY IHS OF VAL VERDE, LLC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2022 |
| CSV RHEA MANAGEMENT HOLDCO, LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 04/01/2022 |
| DWD TX HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 04/01/2022 |
| JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 04/01/2022 |
| REG HG OPCO 1, LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 04/01/2022 |
| REG HG OPCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 04/01/2022 |
| REG OPERATOR HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 04/01/2022 |
| REGENCY INTEGRATED HEALTH SERVICES LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2022 |
| REGENCY TEXAS HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 04/01/2022 |
| BAIRD, DANIEL | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 04/13/2021 |
| CARVAJAL, ANTONIO | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 05/16/2024 |
| CHARTRAND, DANIEL | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 05/19/2014 |
| CLAPP, BARBARA | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 06/01/2021 |
| CORTESE, DAREN | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 08/10/2021 |
| DIAZ, CRIS | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 05/25/2022 |
| GIBSON, PATRICIA | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 08/01/2021 |
| GONZALES, VERONICA | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 05/16/2024 |
| JURADO, JORGE | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | — | since 10/13/2023 |
| KAUFMAN, NICOLE | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 08/10/2021 |
| MANDELBAUM, ELLIOT | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2025 |
| OTAZO, JULIO | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 05/25/2022 |
| PALMER, ROBIN | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 11/18/2020 |
| DEKOWSKI, DONOVAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2022 |
| GUERRA, MARIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/02/2024 |
| 100 HERRMANN DRIVE LLC | Organization | ADP OF THE SNF | — | since 04/01/2022 |
| REGENCY IHS CLINICAL CONSULTING, LLC | Organization | ADP OF THE SNF | — | since 04/01/2022 |
| REGENCY IHS MASTER TENANT LLC | Organization | ADP OF THE SNF | — | since 04/01/2022 |
| REGENCY IHS REHAB LLC | Organization | ADP OF THE SNF | — | since 04/01/2022 |
| GUTIERREZ, JAIME | Individual | ADP OF THE SNF | — | since 05/01/2014 |
| JIMENEZ, ALFONSO | Individual | ADP OF THE SNF | — | since 01/01/2025 |
| REYES, SARAH | Individual | ADP OF THE SNF | — | since 01/01/2025 |
CMS files one row per role, so the 41 rows in the source record cover these 32 parties — each is shown once here with every role it holds. Nothing is omitted.
14 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 75% 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. 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
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 2026-09-01 — CMS provider number 675395. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-08-12, 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.