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Prairie Meadows Rehabilitation and Healthcare Cent

1615 Eleventh St, Floresville, TX 78114 · For profit - Limited Liability company · 120 certified beds · (830) 216-7090 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Nov 20244 immediate-jeopardy citations$33,059 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
Worth asking about
  • 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 cited 4 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $33,059 in federal fines (most recent 2026-01-04)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
921 10th St · (830) 216-7979 · Call to confirm hours
Pharmacy
925 10th St · (830) 393-8098 · Call to confirm hours
Grocery
925 10TH STREET
Park
1823 5th St · Typically dawn to dusk
Place of worship

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 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 fell from 3 to 1 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.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased22.6%15.8%15.4%worse
Long-stay residents who lose too much weight4.5%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.9%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.2%3.3%3.3%typical
Long-stay residents whose ability to walk worsened22.2%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication17.2%18.0%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers1.2%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control12.6%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table13.8%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine92.1%88.0%79.4%better
Long-stay hospitalizations per 1,000 resident days1.722.171.67typical
Long-stay outpatient ER visits per 1,000 resident days2.812.061.80worse

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.

51.9% 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 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.9%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
0.25U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF51.9%CMS range 35.3–69.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 7.5–16.010.7%Oct 2022–Sep 2024no 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 3.6–13.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 2022–Sep 2024CMS 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

0.38
RN hours/ resident / day
0.96
LPN hours/ resident / day
2.53
Aide hours/ resident / day
3.87
Total nurse hours/ resident / day
0.28
RN hoursweekends
30.6%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 120 beds and averages 59.8 residents a day — about 50% occupied, or roughly 60 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 3.87 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.56 hrs/resident/day on weekends vs 4.00 on weekdays — 11% thinner on weekends. RN hours go from 0.42 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 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

5
deficiencies at the latest standard inspection (2025-08-29)
5
at the previous standard inspection (2024-07-26)

Deficiencies are unchanged from the previous inspection. 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.

ABCDEFGHIJKL

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.

27 citations, most serious first. The 14 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · J2026-01-04 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 Residents (Resident #1) reviewed for care plans.The facility failed to develop and implement a care plan that addressed Resident #1's wound on his left buttock identified as a stage 3 pressure ulcer (a bed sore which is an open wound that extends through the skin down into the fatty tissue, appearing as a deep crater but the bone, tendon or muscle are not exposed) by the Wound Care NP A on 11/20/2025 until 12/31/2025, 41 days later; did not address his refusals of skin assessments or wound care in the care plan and incorrectly listed the wound on his right buttock instead of his left. On 12/24/2025 maggots were observed in the stage 3 pressure…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2026-01-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure that a resident received care, consistent with professional stands of practice, to prevent pressure ulcers for 1 of 3 residents (Resident #95) reviewed for Pressure Ulcers. The facility failed to implement the Wound Care NP recommendations for 8 days when Resident #1 was identified with a stage 3 pressure injury to the left buttock from 11/20/2025 to 11/28/2025. Resident #1 refused wound care 22 times from 11/28/2025 to 12/24/2025, and refused further assessment of the wound from the Wound Care NP. On 12/24/2025, Resident #1 had maggots in his wound and the wound had increased in size from 4 cm x 5 cm x 0.2 cm on 12/10/2025 to 6 cm x 3.5 cm x 2 cm on 12/24/2025. An IJ situation was identified on 01/02/2026. The IJ template was provided to the facility on [DATE] at 09:13 PM. While the IJ was removed on 01/04/2026, the facility remained out of compliance at a scope of isolation and severity level of no actual harm with potential for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2026-01-04 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that it was free of pests and rodents for 1 of 1 residents (Resident #1) reviewed for pest control program. The facility failed to ensure Resident #1 was not found with maggots in his left stage 3 buttock wound on 12/24/25. An IJ was identified on 1/1/26. The IJ template was provided to the facility on 1/1/26 at 8:25 p.m. While the IJ was removed on 1/3/26 at 7:24 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility's need to monitor the implementation and effectiveness of its Plan of Removal. The failure could place residents with wounds at risk for infection or infestations from pests. The findings include: Record review of Resident #1's face sheet revealed he was a [AGE] year-old male who readmitted to the facility on [DATE] with diagnoses 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2024-11-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for accidents and supervision, in that: The facility failed to provide adequate supervision and assistive devices to prevent accidents when Resident #1 was confused and required assistance to ambulate. A fall mat was not in place and the bed was not in a low position, and Resident #1 fell out of bed and sustained a left femoral neck hip fracture. An IJ was identified on 11/26/2024. The IJ template was provided to the facility on [DATE] at 4:50 PM. While the IJ was removed on 11/27/2024, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility needed to monitor the implementation of the plan of removal. These failures placed the resident at risk for accidents and serious injuries. Findings included: Record review…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-26 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 17 residents (Resident #3) reviewed for assessments: The facility failed to ensure Resident #3's Annual MDS dated [DATE] indicated she was PASRR positive. These failures could place residents at risk for inadequate care due to inaccurate assessments.Findings included: Record review of Resident #3's face sheet dated 06/23/2026 revealed an admission date of 03/28/2024, with diagnoses that included: Epilepsy (condition that causes recurring seizures) , Insomnia (sleep disorder), Impulse disorder (psychiatric conditions characterized by an inability to resist urges or impulses), Intellectual disabilities (condition characterized by significant limitations in intellectual functioning and adaptive behavior), Hyperlipidemia (condition of high cholesterol or fats in the blood) and, anxiety disorder (worry that are difficult to control and interfere with day-to-day activities).…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-26 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 disease and infection for 1 of 17 residents (Residents #17) reviewed for infection control, in that: The facility failed to ensure CNA A sanitized his hands and changed gloves between residents and while providing incontinent care for Resident #17. These deficient practices could place residents at-risk for infection due to improper care practices. Findings included: Record review of Resident #17's face sheet, dated 06/25/2026, revealed the resident was admitted to the facility on [DATE] and, readmitted on [DATE], with diagnoses which included: Dysphagia (Difficulties swallowing), Dementia (Pattern of mental decline), Malignant neoplasm of brain (Brain cancer) and. Hypertension (High blood pressure), Record review of Resident #17's Quarterly MDS, dated…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-20 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 4 residents reviewed for quality of care. The facility failed to accurately perform a head-to-toe-readmission assessment of Resident #1 on 12/11/25 and did not identify and assess a peripheral IV catheter located on the resident's chest until 12/14/25. This failure placed the resident at risk for complications including infection, infiltration (leakage of IV fluid or medication into the surrounding tissue instead of the vein, which can cause swelling, pain, and tissue damage), and dislodgement (movement or accidental removal of the IV catheter from the vein, which can cause bleeding, injury, or infection).Findings included: Record review of Resident #1's admission record, dated 2/18/26, revealed an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included atrial…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide 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, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 4 residents (Resident #2, and Resident #4) reviewed for incontinent care: 1. The facility failed to ensure CNA A wiped between Resident #2's labia folds during incontinent care. 2. The facility failed to ensure Resident #2's catheter bag was not touching the floor during incontinent care. 3. The facility failed to ensure Resident #4's catheter bag was not touching the floor. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.1. Record Review of Resident #2's admission Record, dated 2/20/26, revealed a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE] with diagnoses including anoxic brain damage (brain injury caused by lack of oxygen resulting in impaired neurological function), contracture of muscle, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-20 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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 maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 4 residents (Residents #1) reviewed for medical records. The facility failed to ensure Resident #1's medication administration report did not contain blanks. This deficient practice could place residents at risk of delayed or improper care due to inaccurate medical records.Record review of Resident #1's admission record, dated 2/18/26, revealed an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included atrial fibrillation (an irregular and often rapid heart rhythm that can increase the risk of stroke and decreased cardiac efficiency), type 2 diabetes mellitus (a chronic condition in which the body does not effectively use insulin, resulting in elevated blood glucose levels), Gastroesophageal Reflux Disease (GERD) (a digestive disorder in which…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-04 · tag F0583 — failed to protect personal privacy — isolated
    Keep 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 personal privacy for 1 of 6 residents (Resident #8) reviewed for privacy, in that: LVN J provided tracheostomy care for Resident #8 with the resident room door open, curtain separating A and B bed open and window blinds open. This failure could affect residents receiving tracheotomy care by resulting in loss of dignity and low self-esteem. The findings were: Record review of Resident #8's undated face sheet revealed Resident #8 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (complete lack of oxygen to the brain leading to brain damage), dementia (a general term for impaired ability to remember, think, or make decisions) and tracheostomy status (surgical procedure that creates an opening through the neck into the windpipe that helps maintain an airway for a person who has difficulty breathing). Record review of Resident #8's quarterly MDS assessment, dated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-04 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 1 of 6 residents (Resident #8) reviewed for infection control in that: LVN J did not wear a gown when providing direct care to Resident #8 who had a tracheotomy and was on enhanced barrier precautions (EBP). This failure could affect residents on enhanced barrier precautions and place them at risk for infection. The findings were: Record review of Resident #8's undated face sheet revealed Resident #8 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (complete lack of oxygen to the brain leading to brain damage), dementia (a general term for impaired ability to remember, think, or make decisions) and tracheostomy status (surgical procedure that creates an opening…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-08-29 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 in one of one kitchen. 1. The facility failed to ensure a case of cinnamon rolls was properly sealed in the reach-in freezer. 2. The facility failed to ensure the interior of the ice machine in the kitchen was free of dirt and debris. 3. The facility failed to ensure opened bags of graham cracker crumbs, cookie pieces, cake mix and frosting mix were sealed in the dry storage room [ROOM NUMBER]. The facility failed to ensure opened bag of snacks and cookies were sealed in the kitchen. 5. The facility failed to record the chemical sanitizing solution concentrations of the dish machine on the log sheet in the dish room. These failures could place residents at risk for food borne illness. The findings included: 1. Observation on 08/26/2025 at 10:44 AM revealed one 28-lb. case of mini cinnamon rolls in a chest freezer in the middle 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that for a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 12 residents (Residents #49 and #52) reviewed for indwelling catheters and perineal/incontinent care, in that: The facility failed to ensure Resident #49's and Resident #52's indwelling catheter tubing were not attached to leg straps to prevent pulling or tugging on the urethra on 08/26/25. These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections due to improper care. The findings included: 1.Record review of Resident #49's face sheet, dated 8/16/25, revealed an [AGE] year old male admitted 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 3 the residents (Resident # 49) reviewed for oxygen in that: The facility failed on 8/26/2025to ensure that Resident #49's nebulizer tubing was bagged. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications. The findings included: Record review of Resident #49's face sheet, dated 8/16/25, revealed an [AGE] year old male admitted to facility on 3/1/2025 with the diagnosis that included: Benign Prostatic Hyperplasia ( an enlarged prostate ), Type 2 diabetes ( is a chronic condition where your body either doesn't use insulin properly, leading to high blood sugar levels) and Pleural effusion,(is the buildup of excess fluid in the pleural space between the lungs and chest wall) Record review of Resident #49's Quarterly MDS, dated [DATE],…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Dcited before2025-08-29 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that in accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 of 3 residents (Resident #58) reviewed for medication storage in that: The facility failed on 8/26/25 to ensure medications were not left on Resident #58's bedside table. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered. The findings included: Record review of Resident #58's face sheet, dated 8/26/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Hypertension (is when the force of blood pushing against your artery walls is consistently too high) , Depression (persistent feeling of sadness and loss of interest), and Spinal Cord Infarction (Injury to the spinal cord ) Record review of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-06 · tag F0839 — isolated
    Employ staff that are licensed, certified, or registered in accordance with state laws.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable state laws for 1 of 4 (LPN A) staff reviewed for staff qualifications. The facility failed to ensure LPN A's nursing license was not expired between [DATE] and [DATE]. This failure could place residents at risk for not receiving nursing services by a licensed nurse. The findings included: Record review of the staff roster for the facility indicated LPN A had been employed at the facility since [DATE]. Record review of the Texas Board of Nursing license verification, dated [DATE], indicated LPN A was originally issued a LVN/LPN license on [DATE] and current expiration date was [DATE]. During an interview on [DATE] at 04:26 p.m., the ADMIN revealed LPN A was notified of LPN A's expired license on [DATE]. LPN A was suspended until her license was renewed. The ADMIN revealed LPN A had only worked one or two shifts between Saturday, [DATE] and Friday, [DATE].…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-06 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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, interviews, and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for clinical records. The facility failed to ensure Resident #1's weights were documented in his medical record for 4 of 5 weeks (weeks of 03/13/2025, 03/20/2025, 03/27/2025, and 04/03/2025) reviewed. This failure could place residents at risk of not receiving the care and services needed. Findings included: Record review of Resident #1's admission Record, dated 06/03/2025, reflected an [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #1's Diagnosis Report, dated 06/03/2025, reflected a principal diagnosis of cerebral infarction (a disruption in the brain's blood flow) due to embolism (a clot related to foreign material that reduces blood flow) of right anterior cerebral artery (artery…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-27 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 was made for 1 (Resident #1) of 6 residents reviewed for reporting of alleged violations, in that: The facility failed to report to the state agency, an incident of neglect regarding Resident #1, after he had an unwitnessed fall in his room with a possible injury to his hip that occurred on 11/01/2024. The unwitnessed fall later revealed through CT scan (a scan to create cross sectional images of organs, bones, and other tissues), Resident #1 had a left femoral hip fracture, and it was not reported to the state as of 11/06/2024. This failure could place facility residents at risk of hard due to delays in reporting allegations of injury of unknown origin, abuse, and neglect. Findings included: Record review of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-26 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to protect the residents' right to reside in a safe, clean, comfortable, and homelike environment for 4 of 23 residents (Residents #43, #48, #45, and #31) reviewed for a safe, clean, and comfortable environment, in that: 1. Resident #43's bathroom floor molding which measured approximately 1.5 feet by 4 inches was removed from the wall. 2. Resident #48's bathroom ceiling vent which measured approximately 6x4 inches was rusty and covered with dirt particles. 3. Resident #45's bathroom ceiling vent which measured approximately 6x4 inches and the bedroom ceiling vent which measured approximately 1.5 feet by 4 inches were covered with dust and dirt particles. 4. Resident #31's toilet was running and would not stop on it's own. These deficient practices could lead to diminished quality of life and psychosocial harm. The findings were: 1. Observation of Resident #43's bathroom on 07/23/24 at 10:15 a.m. revealed that the bathroom floor molding which measured approximately 1.5 feet by 4 inches was detached from 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-26 · tag F0801 — pattern
    Employ 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, in that: The DM 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. The findings included: Record review of the employee personnel file provided by the facility revealed the hire date for the DM was 10/20/2023. Further review of the personnel file, which included the DM's resume, revealed no documented evidence the DM was: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Had similar…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation, in that: 1. There was a bag of strawberries in the reach-in freezer without a label indicating a use-by date. 2. There was a loaf of bread in the dry storage room past its use-by date. 3. There were three packages of tortillas in the dry storage room past their use-by date. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 07/23/2024 at 10:17 AM inside the reach-in freezer revealed a gallon-sized zip-locked bag of frozen strawberries. There was no marking on the bag indicating the storage or use-by date. 2. Observation on 07/23/2024 at 10:19 AM in the dry storage room revealed one unopened loaf of wheat bread with a facility date of 7/10 on the wrapper. The best by date 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 2 of 3 the residents (Residents #16 and #37) reviewed for respiratory care, in that: The nebulizer tubing of Residents #16 and #37 was on their bedside tables unbagged and undated. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications. The findings were: 1. Record review of Resident #16's face sheet, dated 7/23/24, revealed a 74-year male admitted to the facility on [DATE] with the diagnoses that included Spina bifida (a birth defect in which there is incomplete closing of the spine and the membranes around the spinal cord), Asthma (is a chronic lung disease that causes the airways in the lungs to become inflamed and narrowed), and medical condition in which the bones become brittle and fragile from loss of tissue. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-26 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly for 1 of 5 residents (Resident #16) reviewed for medication storage, in that: The facility failed to ensure medications were not left on Resident #16's bedside table. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered. The findings were: Record review of Resident #16's face sheet, dated 7/23/24, revealed a 74-year male admitted to the facility on [DATE] with the diagnoses that included Spina bifida (a birth defect in which there is incomplete closing of the spine and the membranes around the spinal cord), Asthma (is a chronic lung disease that causes the airways in the lungs to become inflamed and narrowed), and medical condition in which the bones become brittle and fragile from loss of tissue. Record review of Resident #16's Quarterly MDS, dated [DATE], revealed a BIMS of 13, which indicated intact cognition.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-06-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen. The facility failed to ensure the freezer in the main kitchen had a thermometer; the food in the refrigerator was stored properly and not used past 3 days from storing it; the kitchen equipment was clean; the pans were completely dry before stacking them; the food was covered after preparation; there were no flies in the kitchen and that Dietary Staff wore their hair net containing the hair on the back of their head. These deficiencies affected all residents who received food from the kitchen and could contribute to foodborne illness. The findings were: Observation and interview on 06/06/23 at 10:45 AM, during initial tour of the kitchen, revealed the freezer in the main kitchen did not have a thermometer. It contained fortified milk shakes provided to residents. Further observation revealed the DM emptied the contents of the freezer. Interview with the DM revealed there was not a thermometer…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-09 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    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 arrange for the provision of hospice care under a written agreement to coordinate care provided by the LTC facility and hospice staff for 2 of 5 residents (Residents #13 and #55) reviewed for hospice services. 1. The facility failed to obtain Resident #13's most recent hospice Plan of Care, Physician's certification of the terminal illness and interdisciplinary documentation of the hospice staff providing services to the resident. 2. The facility failed to obtain Resident #55's most recent hospice Plan of Care, Physician's certification of the terminal illness and interdisciplinary documentation of the hospice staff providing services to the resident. These failures could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: 1. Record review of Resident #13's face sheet, dated 06/09/2023, revealed 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-08-29 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed a to dispose of garbage and refuse properly for 2 of 3 Dumpsters (Dumpsters #1 and #3) reviewed for garbage and refuse disposal. The facility failed to ensure Dumpster #1 had a drainage plug and Dumpster #3 was free of gaps. These deficient practices could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings included: Observation on 08/28/2025 at 10:17 AM revealed Dumpster #1 was missing a drainage plug. Observation on 08/28/2025 at 10:18 AM revealed the bottom of the left side of Dumpster #3 had a gap approximately 9 in length and 1 in height due to rust. During an interview on 08/28/2025 at 10:19 AM, the DM stated she was unaware Dumpster #1 was missing a drainage plug and Dumpster #3 had the gap caused by rust at the bottom, and it was important for both dumpsters to be completely sealed to prevent leakage and for the proliferation of rodents. Record review of the facility policy Food-Related Garbage and Refuse Disposal, dated October 2022, revealed,…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-11-27 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 post daily 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 2 days (11/05/2024 and 11/06/2024) of 3 days reviewed. The facility did not post the required current nurse staffing information for 11/05/2024 and 11/06/2024. 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. Findings included: During an observation on 11/06/2024 at 04:25 p.m., a document labeled Daily Nurse Staffing Report dated 11/04/2024, was posted in a plastic sheet protector and taped next to the nurses' station and at the entry to the resident 200-hall. During an observation and interview on 11/06/2024 at 04:40 p.m., the DON stated the night nursing shift was typically responsible for posting the daily census…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$33,059 in federal fines across 2 penalties.

  • $19,432 — penalty dated 2026-01-04
  • $13,627 — penalty dated 2024-11-27

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 NEXION HEALTH — 51 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 →

RatingThis homeChain avg
Overall 1 of 52.2-1.2 vs chain
Health inspection 1 of 52.3-1.3 vs chain
Staffing 3 of 52.8+0.2 vs chain
Quality measures 3 of 52.6+0.4 vs chain
The other 50 homes this chain runs (chain average 2.2★, per CMS)
1 of 5Bay Ridge Healthcare CenterLa Porte, TX 1 of 5Claiborne Healthcare CenterShreveport, LA 1 of 5Cornerstone Rehabilitation And Healthcare CenterCorinth, MS 1 of 5Crystal Rehabilitation And Healthcare CenterGreenwood, MS 1 of 5Duncanville Healthcare and Rehabilitation CenterDuncanville, TX 1 of 5Flatonia Healthcare CenterFlatonia, TX 1 of 5Gonzales Healthcare CenterGonzales, LA 1 of 5Green Valley Healthcare and Rehabilitation CenterFort Worth, TX 1 of 5Grenada Rehabilitation And Healthcare CenterGrenada, MS 1 of 5Holly Springs Rehabilitation And Healthcare CenterHolly Springs, MS 1 of 5Indianola Rehabilitation And Healthcare CenterIndianola, MS 1 of 5Lily Springs Rehabilitation and Healthcare CenterLampasas, TX 1 of 5Meadowview Health & Rehab CenterMinden, LA 1 of 5New Iberia Manor SouthNew Iberia, LA 1 of 5Patterson Healthcare CenterPatterson, LA 1 of 5Picayune Rehabilitation And Healthcare CenterPicayune, MS 1 of 5Pierremont Healthcare CenterShreveport, LA 1 of 5The Bluffs Rehabilitation And Healthcare CenterVicksburg, MS 1 of 5Village Creek Rehabilitation and Nursing CenterLumberton, TX 1 of 5Willow Park Rehabilitation Health Care CenterClifton, TX 1 of 5Woodlands Rehabilitation And Healthcare CenterClinton, MS 1 of 5Yazoo City Rehabilitation And Healthcare CenterYazoo City, MS 2 of 5Great Oaks Rehabilitation And Healthcare CenterByhalia, MS 2 of 5Kaplan Healthcare CenterKaplan, LA 2 of 5Many Healthcare and Rehabilitation CenterMany, LA 2 of 5New Iberia Manor NorthNew Iberia, LA 2 of 5North Star Ranch Rehabilitation and Healthcare CenBonham, TX 2 of 5Willow Park Rehabilitation And Care CenterWillow Park, TX 3 of 5Barton Valley Rehabilitation and Healthcare CenterAustin, TX 3 of 5Cedar Ridge Rehabilitation and Healthcare CenterPilot Point, TX 3 of 5Columbia Rehabilitation And Healthcare CenterColumbia, MS 3 of 5Cross Timbers Rehabilitation and Healthcare CenterFlower Mound, TX 3 of 5Delta Rehabilitation And Healthcare CenterCleveland, MS 3 of 5Golden Creek Healthcare And Rehabilitation CenterNavasota, TX 3 of 5Lakeview Rehabilitation and Healthcare CenterWinnsboro, TX 3 of 5Lone Star Ranch Rehabilitation and Healthcare CentKingsville, TX 3 of 5Midwestern Healthcare CenterWichita Falls, TX 3 of 5Natchez Rehabilitation And Healthcare CenterNatchez, MS 3 of 5Ridgecrest Healthcare And Rehabilitation CenterForney, TX 4 of 5Arbor Hills Rehabilitation And Healthcare CenterEagle Lake, TX

Showing 40 of 50; 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 / managerTypeRoleSince
BRENDE, MARTIIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
MAK, DAVIDIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 05/18/2021
NEXION HEALTH AT FLORESVILLE, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
FALLON, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
HERDRICH, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
KIRLEY, FRANCISIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
LEE, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
REID, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
RINER, MEERAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021

CMS files one row per role, so the 11 rows in the source record cover these 9 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.

$5.2M
Net patient revenuemost recent cost report
+2.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 55%Medicare 7%Other / private 37%

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

$231per resident / day
operating cost
$7,032per month
≈ monthly operating cost
$236per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

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 675446. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-29, 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.

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