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Cross Timbers Rehabilitation and Healthcare Center

3315 Cross Timbers Rd, Flower Mound, TX 75028 · For profit - Corporation · 120 certified beds · (972) 724-0996 Medicare & Medicaid certified

Call the home — (972) 724-0996 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Feb 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$8,281 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
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 recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,281 in federal fines (most recent 2025-09-11)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3101 Churchill Dr · (972) 874-5588 · Call to confirm hours
Pharmacy
4001 Long Prairie Rd · (469) 771-4117 · Call to confirm hours
Grocery
Kroger0.6 mi
2709 Cross Timbers Rd · (972) 355-0997 · Call to confirm hours
Park
3332 Cross Timbers Rd · Typically dawn to dusk
Place of worship
3415 Cross Timbers Rd · (972) 539-9341

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
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 increased11.9%15.8%15.4%better
Long-stay residents who lose too much weight3.9%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 symptoms0.7%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 injury1.3%3.3%3.3%better
Long-stay residents whose ability to walk worsened14.7%14.0%16.1%typical
Long-stay residents on antianxiety or hypnotic medication22.1%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine87.4%98.0%95.3%typical
Long-stay residents with pressure ulcers3.2%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control12.3%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table12.0%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine70.6%88.0%79.4%worse
Short-stay residents rehospitalized after admission29.9%25.7%22.6%worse
Short-stay residents with an outpatient ER visit6.5%12.3%12.0%better

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.

46.2% 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 78 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.2%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
40.0%U.S. median 56.6%
Met the expected recovery
0.25U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 40.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 35 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 0.25 therapist hours per resident per day in 2026Q1 — more than 34% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 SNF46.2%CMS range 38.0–57.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 7.1–15.710.7%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 discharge40.0%56.6%Oct 2024–Sep 2025CMS 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 discharge60.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge37.1%50.0%Oct 2024–Sep 2025CMS 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 identified97.9%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this 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 hospitalization8.0%CMS range 5.0–12.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 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

0.55
RN hours/ resident / day
0.78
LPN hours/ resident / day
2.39
Aide hours/ resident / day
3.71
Total nurse hours/ resident / day
0.68
RN hoursweekends
49.5%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 90.9 residents a day — about 76% occupied, or roughly 29 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.548 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.39 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 3.45 hrs/resident/day on weekends vs 3.82 on weekdays — 10% thinner on weekends. RN hours go from 0.50 to 0.68 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2026-04-16)
9
at the previous standard inspection (2025-01-24)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-09-11 · 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 each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent him from eloping from the facility on 05/05/25. He was found down the street away from the facility and was brought back by the local police department. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 05/05/24 and ended on 05/06/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents who require supervision at risk of harm, severe injury, and possible death. Findings included: Record review of Resident #1's Quarterly MDS Assessment, dated 09/16/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS (mental status assessment) score of 09…

    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 · Past Non-Compliance
  • Potential for harm · D2026-04-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide residents with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for two (Resident #15 and Resident #65) of six residents reviewed for call lights. 1. The facility failed to ensure Resident #15's call light was not underneath her bed pillows so that she could contact staff for assistance to remove bed covers for her. 2. The facility failed to ensure Resident #65's call light was accessible so that she could request her catheter to be emptied. This failure could place the residents at risk of falling, further injury, and unnecessary pain from not being able to call for help. Findings included:1. Record review of Resident #15's Comprehensive MDS Assessment, dated 03/11/26, reflected [AGE] year-old female admitted to the facility on [DATE] with a BIMS of 10 indicating moderate cognitive impairment. Resident #15 had the following…

    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 · D2026-04-16 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents receive proper treatment and care to maintain good foot health by providing foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 19 resident (Resident #8) reviewed for foot care.The facility failed to ensure Resident #8's toenails were trimmed.This failure had the potential to affect place residents by placing them at risk for poor personal hygiene, odors and a decline in their quality of life. Findings included:Record review of Resident #8's 5-day MDS assessment dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Resident #8 had diagnoses which included metabolic encephalopathy (brain dysfunction), muscle wasting and atrophy (the loss or thinning of muscle tissue), depression (mood disorder), Non-Alzheimer's Dementia (problems with memory and thinking), hypertension…

    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 before2026-04-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    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 is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections based on the resident's comprehensive assessment for 1 of 3 residents (Residents #65) reviewed for urine incontinence/catheters. The facility failed to ensure Resident #65's catheter urine collection bags were emptied in a timely manner. This failure could place residents with catheters at risk of infections and loss of dignity. Findings included: Record review of Resident #65's Quarterly MDS Assessment, dated 04/04/26, reflected [AGE] year-old female admitted to the facility on [DATE] with a BIMS of 09 indicating moderate cognitive impairment. Resident #15 had the following diagnoses: Heart Failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs), high blood pressure (force of blood against the artery wall is consistently too high), Renal Insufficiency (kidney…

    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 · D2026-04-16 · 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 a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 (Resident #59 and Resident #61) of 3 residents reviewed for respiratory care. The facility failed to ensure that Resident #59 and Resident #61 received adequate oxygen to maintain their O2 sat above 92 % per physician's orders. This failure could place residents who receive oxygen therapy at risk of receiving inadequate oxygen support, which could result in serious harm. Findings included: 1.Record review of Resident #59's Quarterly MDS assessment dated [DATE], revealed at [AGE] year-old female who admitted to the facility on [DATE]. The resident's BIMS score was 14, which indicated intact cognition. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #4 required moderate assistance with most self-care ADLs. The MDS Assessment under Section I-Active Diagnoses, reflected Resident #59'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-16 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 laboratory services to meet the needs of its residents for 1 of 5 residents (Resident #4) reviewed for laboratory services. The facility failed to provide proper monitoring of Resident #4's immunodeficiency disorder by not completing routine specialized laboratory services to ensure that treatment remained effective. This failure could place residents at risk of a delay in medical evaluation and treatment, which could result in worsening of conditions or serious harm. Findings included: Record review of Resident #4's Annual MDS Assessment, dated 03/20/26, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident's BIMS score was 15, which indicated intact cognition. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #4 was independent with all self-care ADLs. The MDS Assessment under Section I-Active Diagnoses, reflected Resident # 4's active 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-16 · 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 resident rooms (Resident #15's room) reviewed for infection control. The facility failed to remove and dispose of Resident #15's wound care trash and debris, which included a cup of gauze soaked with betadine and used wound care debris trash, from Resident #15's bedside table. This failure could place residents at risk of exposure to communicable diseases and infections.Findings included:Record review of Resident #15's Comprehensive MDS Assessment, dated 03/11/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with a BIMS of 10 indicating moderate cognitive impairment. The MDS reflected Resident #15 had the following diagnoses: stroke (sudden interruption of blood…

    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 · D2026-02-26 · 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 observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #1) reviewed for care plans.The facility failed to develop a comprehensive person-centered care plan for Resident #1 that addressed her religious dietary restrictions.This failure could lead to the residents' personal choices and desires not being met. Findings included:Record review of Resident #1's quarterly MDS assessment, dated 12/18/25, reflected that Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included stroke affecting the resident's vision, Asperger's syndrome (form of Autism with social and communication issues), and diabetes. Her Functional Abilities assessment indicated she used 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 interdisciplinary team determined if a resident was able to self-administer medications d for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility's interdisciplinary team failed to ensure Resident #1 was clinically appropriate to self-administer Systane ophthalmic eyedrops that were at the resident's bedside. The failure had the potential to place residents at risk for unsafe drug administration. Findings included:Record review of Resident #1's admission MDS, dated [DATE], reflected Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's BIMS score of 14, which indicated his cognition was intact. Resident #1's MDS was pending completion. Record review of Resident #1's Baseline Care Plan, admission date 10/04/25, reflected Section D. Medications revealed Resident #1 was not able to self-administer any medications. Record review of Resident #1's clinical records…

    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 · E2025-01-24 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such 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 ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (Residents #26 and #245) reviewed for dialysis. The facility failed to ensure dialysis communication forms for Residents #26 and Resident #245 were received back after returning from dialysis treatment. This failure could place residents at risk of inadequate communication between the facility and dialysis center. Findings included: 1. Record review of Resident #26's admission MDS assessment, dated 01/12/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #26 had a diagnosis of end stage renal disease (a chronic condition that occurs when the kidneys can no longer filter waste from the blood and requires long-term dialysis). She had a BIMS score of 13, which indicated her…

    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 · E2025-01-24 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide 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 on one of three medication carts (200) and 2 of 19 residents (Residents #1, #3, and #190) reviewed for pharmacy services. 1. The facility failed to ensure the 200 Hall nurses' medication cart contained accurate narcotic logs for Resident #1 and #3. 2. The facility failed to ensure Resident #190's physician order for Lomotil was followed when Hospice Nurse G faxed the order on 01/20/25 to the facility, and it was not put in the system until 01/22/25. These failures could place residents at risk for medication errors, drug diversion, and delay in medication administration. Findings included: 1. Record review of Resident# 1's Quarterly MDS Assessment, dated 01/08/25, reflected the resident was [AGE] year-old female readmitted to the facility 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · E2025-01-24 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 when the pharmacist reported any irregularities to the attending physician and the facility's medical director and director of nursing, these reports were acted upon for 3 of 5 residents (Residents #35, #44, and #39) reviewed for medication regimen review. 1. The facility's failed to ensure the Pharmacist Consultant recommendation for Residents #35's antipsychotic medication, Quetiapine Fumarate (Seroquel), were was reviewed by the physician for the identified irregularities. 2. The facility's failed to ensure the Pharmacist Consultant recommendation for Residents #44's antipsychotic medication, Quetiapine Fumarate (Seroquel), were was reviewed by the physician for the identified irregularities. 3. The facility failed to ensure the pharmacy consultant recommendation was sent to the physician for review for Resident #39's psychotropic medication, duloxetine (Cymbalta). These failures could place residents at risk for medication errors,…

    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 · E2025-01-24 · tag F0761 — failed to label and store drugs safely — pattern
    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 all drugs and biologicals were stored securely for 1 of 25 residents (Resident #45) and had acceptable labeling for 2 of 4 medication carts (medication cart for Halls 200 and 300) reviewed for labeling and storage. 1. The facility failed to ensure Resident #45's 1 bottle of thymus 300 capsules, 1 bottle of thyroid 130 capsules, 1 bottle of Advil 200 mg, and 1 bottle of Tylenol 500 mg stored at the resident's bedside table were locked in a lock box or secured in the medication cart or medication room. 2. The facility failed to ensure insulin vials were dated after they were opened. This failure could place residents at risk of not receiving the therapeutic dose of medication. Findings included: Record review of Resident# 45's Quarterly MDS Assessment, dated [DATE], reflected the resident was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included cancer (with or without metastasis) (when cancer…

    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 · E2025-01-24 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 the facility provided food that was palatable, for 1 of 3 observed meals (the lunch meal on 01/22/25) reviewed for dietary services. The facility failed to serve food that had a smooth, puddling like texture during the lunch meal on 01/22/25. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life. Findings included: Observation on 01/22/25 at 10:00 AM of the kitchen revealed [NAME] F was boiling spaghetti pasta on the stove and after being fully cooked, she added them to the machine to puree the food. [NAME] F pureed the cooked pasta, but it still had bits of pasta in it and was not smooth or pudding like. A sample tray was requested and tasted on 01/22/25 at 1:45 PM with three state surveyors and the DM. The tray that was tasted included pureed spaghetti meat sauce, pureed bread, pureed vegetables, and pureed pasta. The pureed pasta was chunky with pieces of cooked pasta chunks in it; it did not have a smooth or pudding…

    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 before2025-01-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    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 provide appropriate treatment and services, based on the comprehensive assessment, to prevent urinary tract infections for 1 of 3 residents (Resident #68) reviewed for urinary catheters. The facility failed to keep Resident #68's catheter tubing off the floor while the resident was in her wheelchair causing it to drag on the floor and be stepped on while she was being pushed down the hall. This failure could affect residents with catheters by placing them at risk for the development and/or worsening of urinary tract infections and injury. Findings included: Record review of Resident #68's MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included depression, bipolar disorder, dorsalgia (physical discomfort occurring anywhere on the spine or back, ranging from mild to disabling), disorder of kidney and ureter. Resident #82 has a BIMS of 5 indicating she had severe…

    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 · D2025-01-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 interview and record review, the facility failed to ensure, based on a resident's comprehensive assessment, residents maintained acceptable parameters of nutritional status for 1 of 19 residents (Resident #68) reviewed for nutrition. The facility failed to obtain Resident #68's weight upon her admission to the facility on [DATE] and failed to obtain weekly weights for the resident for four weeks, which resulted in the resident's weight loss not being identified. This failure placed residents at-risk for loss of weight and inadequate nutrition. Findings included: Record review of Resident #68's admission MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included depression, bipolar disorder, dorsalgia (physical discomfort occurring anywhere on the spine or back, ranging from mild to disabling), disorder of kidney and ureter, cognitive impairment, and malnutrition. Resident #82 has a BIMS of 5 indicating she had severe cognitive…

    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 · D2025-01-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 PRN orders for antipsychotic drugs were limited to 14 days and could not be renewed, unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication and resident's drug regimen was free from unnecessary drugs, to include adequate indications for its use for 2 of 2 residents (Residents #35 and #44) reviewed for unnecessary medications. 1. The facility failed to ensure Resident #35's PRN order for Seroquel (Quetiapine Fumarate) , an antipsychotic medication, did not extend beyond 14 days without an identified end date. 2. The facility failed to ensure Resident #44 did not receive the antipsychotic medication Seroquel (Quetiapine Fumarate) for sleep. This failure could place residents at risk for receiving unnecessary medications and adverse drug reactions. Findings included: 1. Record review of Resident# 35's Quarterly MDS Assessment, dated 01/03/25, reflected the resident 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-24 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 19 residents (Resident #39) reviewed for resident call system. The facility failed to ensure Resident #39 had a working call light. This failure could have placed residents at risk of being unable to obtain assistance when needed. Findings included: Record review of Resident #39's MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included stroke, depression, bipolar disorder, and obstructive sleep apnea (a sleep disorder characterized by repeated episodes of complete or partial blockage of the upper airway during sleep). Resident #39 had a BIMS score of 14, indicating her cognition was intact. Record review of Resident #39's care plan initiated 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-28 · 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 report the results of all investigations to the State Survey Agency (HHSC), within 5 working days of the incident for 1 of 3 facility self-reported incidents (Incident Intake ID: 483847)reviewed for reporting to HHSC. The facility failed to submit a Provider Investigation Report to HHSC within 5 working days of reporting an incident involving allegations of quality of care, administration/personnel, and resident rights regarding Resident #1 on 02/12/24. This failure could place the residents at risk for not having investigations reported within the timeframe as required. Findings included: Record review of the face sheet printed on 02/28/24 indicated Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses including vascular dementia severe with agitation (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), cerebral atherosclerosis (build-up of plaque in the blood vessels 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 · F2023-11-29 · 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

    Based on observation, interview, and record review, the facility failed to store, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen for food storage. The facility failed to: 1. date, label, and seal food items in the dry storage area of the facility's kitchen. 2. [NAME] J, Dietary Aide K and Maintenance Director washed their hands and put on hair restraints prior to entering or directly after entering the kitchen. 3. keep the kitchen clean and sanitary and free from dirt and food debris and well maintained equipment and exit barrier. These failures could affect residents by placing them at risk of cross contamination and food-borne illness which could cause gastro-intestinal illnesses and increase in pests. Findings included: Observation on 11/29/23 at 11:04 am of the facility's kitchen revealed: -Two 32 ounce bags of clear unlabeled Spaghetti noodles were opened with no open on date . -1 very large 64 ounce bag of clear unlabeled spiral noodles were opened without a received and open on date . -1 very large 64 ounce…

    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 · E2023-11-29 · 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 observations, interviews, and record review the facility failed to ensure a safe, clean, comfortable, and homelike environment with housekeeping services for a sanitary, orderly, and comfortable interior for 3 of 3 (Resident #1, Resident #48, and Resident #68) residents' rooms reviewed for environment. The facility failed to ensure Residents (#1, #48, and #68) had clean enteral pump IV poles. These failures could place all residents at risk of cross contamination from dirt and debris which could result in infections. Findings included: Observation on 11/27/23 at 12:18 pm, revealed Resident #48 was sitting up in his wheelchair near the nursing station with the enteral pump IV pole next to him. The enteral pump IV pole was covered in a tan liquid, with a dry tan crust, with greyish dirt, and debris particles stuck to the crusted and dried liquid. The Enteral pump IV pole legs were 90% covered with dirt and debris. Observation on 11/27/23 12:22 pm, revealed Resident #1 was sitting up in his wheelchair near the nursing station with the enteral pump IV pole next to him. 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 · D2023-11-29 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to review and revise care plan after each assessment for one (Residents #12) of six residents reviewed for care plans. The facility failed to complete/revise Residents #12's care plan as being a smoker. This failure could place residents at risk of not receiving individualized care, which could result in a decline and function and mental well- being. Findings included: Record review of Resident #12's Quarterly MDS assessment dated [DATE] revealed a 53- year- old female who admitted [DATE] with a BIMS score of 15 (no cognitive impairment), used a wheelchair with no impaired upper and lower extremities, independent with most ADL care, and occasionally incontinent to bowel and bladder, with 2 or more falls with no injury. Record review of Resident #12's Order Summary Report dated 11/29/23 revealed she took medications for migraines, anxiety, pain, nausea vomiting, depression, schizoaffective (Mood Disorder) disorder, active bladder. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-29 · 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 observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 6 residents (Residents #20 and Resident #69) reviewed for accidents and hazards, in that: 1. The facility failed to ensure an accurate smoking assessment on Resident #20 was completed and followed. 2. The facility failed to ensure Resident #69's wheelchair was safe for him to use. These failures could place residents that use assistive devices and smoke, at risk of accidents, resulting in a decline in their physical condition, and injury. The findings were: 1. Record review of Resident #20's Quarterly MDS assessment dated [DATE] revealed a [AGE] year old female who admitted [DATE] with highly impaired vision (object identification in question, but eyes appear to follow objects) .BIMS score was a 15 (no cognitive impairment) and needed extensive…

    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 before2023-08-15 · 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 interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Residents # 1 and #2) reviewed for accidents. 1. The facility failed to ensure Residents #1 and #2 were provided adequate staff supervision during a smoking session. 2. The facility failed to increase supervision of the residents even though they had negative altercations prior to the altercation in the courtyard. This failure could place residents at risk for further altercations, which could result in injury, pain, and hospitalization. 3. Facility prematurely prepared Resident #3, who required a two-person assisted transfer, using a mechanical lift, for transfer. By the resident having to wait for a second staff to assist with the transfer, she became impatient and attempted to transfer herself, which resulted in a fall. This failure could place residents at risk for accidents or serious injury. Findings Include: A record review of 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.

    Quality of Life and Care 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

$8,281 in federal fines across 1 penalty.

  • $8,281 — penalty dated 2025-09-11

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 3 of 52.2+0.8 vs chain
Health inspection 3 of 52.3+0.7 vs chain
Staffing 3 of 52.8+0.2 vs chain
Quality measures 4 of 52.6+1.4 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 5Prairie Meadows Rehabilitation and Healthcare CentFloresville, TX 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 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 / managerTypeRoleShareSince
EASTLAND MEMORIAL HOSPITAL DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/01/2017
WRIGHT, LABANIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 11/10/2021
NEXION HEALTH AT FLOWER MOUND, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2017
FALLON, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2017
KIRLEY, FRANCISIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2017
LEE, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2017
OSWALD, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/22/2022
PIERCE, DANIELIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/16/2021
RINER, MEERAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2017

CMS files one row per role, so the 10 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$9.3M
Net patient revenuemost recent cost report
+2.2%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 52%Medicare 9%Other / private 39%

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

$282per resident / day
operating cost
$8,566per month
≈ monthly operating cost
$288per 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 675703. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-16, 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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