Galveston Nursing and Rehabilitation Center

Location & what’s nearby

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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

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.

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.

39.5% 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 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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.

Staffing

How full it usually is: this home is certified for 150 beds and averages 64.6 residents a day — about 43% occupied, or roughly 85 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.74 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.78 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.11 hrs/resident/day on weekends vs 2.99 on weekdays — 29% thinner on weekends — a notable drop. RN hours go from 0.73 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 71% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

42 citations, most serious first. The 19 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · Kcited before2026-04-22 · tag F0580 — failed to tell family and doctor about changes — pattern
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority, the resident representative when there was a need to alter treatment significantly, that is a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment for 1 of 3 residents (Resident #1) reviewed for notification. 1. The facility failed to notify Resident #1's NP or MD when Resident #1 refused her medication/s, nutritional supplements, and meal/s from her facility admission on [DATE] through 04/17/2026. 2. The facility failed to ensure Resident #1's physician was notified when the resident had a change in condition and had difficulty swallowing. An immediate Jeopardy (IJ) situation was identified on 04/18/2026. While the IJ was removed on 04/22/2026, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2026-04-22 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
  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 observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 3 residents (Resident #1) reviewed for nutrition status. 1. The facility failed to ensure Resident #1 did not have a significant weight loss of 19% due to losing 23lbs in 12 days. 2. The facility failed to provide Resident #1 with feeding and nutrition via her PEG tube. 3. The facility failed to ensure Resident #1 had dietary recommendations in place from her admission on [DATE] until 4/17/2026, the date of State Surveyor facility entrance. 4. The facility failed to ensure Resident #1 had weekly weights obtained per physician order. 5. The facility failed to address Resident #1's risk of impaired nutrition related to her newly inserted PEG tube status and therapeutic diet…

  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 · Kcited before2024-03-29 · tag F0580 — failed to tell family and doctor about changes — pattern
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 immediately consult with the resident's physician of G- tube dysfunction or malfunction for 1 of 4 residents reviewed for physician notification (Resident #1). The facility failed to immediately consult with the resident's physician when facility staff did not implement physician order due to the inadequate supply of adnominal binder to protect G-tube and G-tube site for 1 of 4 residents reviewed for physician notification (Resident #1). The facility failed to notify the resident's physician of complications related to Resident# 1 G-tube site pain and administering medications to Resident #1 via the G-Tube. The failure resulted in LVN V administering medications by plunger pushing the medications with force into Resident #1 gastrostomy tube instead of administering to gravity, placing the resident at immediate risk for potential harms associated G-Tube blockage and Aspiration (occurs when liquid or food enters the lungs). The facility…

  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
• Immediate jeopardy · K2024-03-29 · tag F0693 — failed to provide proper feeding-tube care — pattern
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of four residents (Resident #1) who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding, in that: The facility failed to implement the physician's order for an abdominal binder indicated to prevent complications of gastrostomy tube. The facility failure resulted in Resident #1 requiring discharge to the hospital for G-Tube replacement. LVN V failed to use the facility's identified proper technique and safety precautions for Resident # 1 for administering medications via G- Tube. LVN V's failure resulted in LVN V administering medications by plunger pushing the medications into Resident #1 gastrostomy tube instead of administering to gravity, placing the resident at immediate risk for potential harms associated G-Tube blockage and Aspiration (occurs when liquid or food enters the lungs). The facility failed to implement physician's order to provide gastrostomy tube…

  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 · Jcited before2024-03-08 · 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 interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 (Resident # 1) of 7 residents reviewed for respiratory care. The facility failed to ensure Resident #1 was provided oxygen during transport to doctors appointment in which Resident #1 arrived to appointment with O2 level at 73%, had difficulty breathing adn required O2. An IJ was identified on 3/7/2024. The IJ template was provided to the facility on 3/7/2024 at 4:20 pm. While the IJ was removed on 3/8/2024, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents who received oxygen therapy at risk of respiratory complications and/or death. The findings included: Record review of Resident # 1's admission…

  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 · Jcited before2023-10-28 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 interviews and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (CR #1) of 5 residents reviewed for resident rights. -The facility failed to notify CR #1's physician when CR #1 became weak, confused, and short of breath which resulted in CR #1 falling and passing away at the facility on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:35 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of not receiving appropriate care, interventions, and/or death. The findings…

  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
• Immediate jeopardy · Jcited before2023-10-28 · 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 interviews and records reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 (CR #1) of 5 residents reviewed for quality of care. -The facility failed to follow physician orders for CR #1 who was weak, confused, and short of breath resulting in a O2 saturation at 90% and who passed away a little under 2 hours later. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:35 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents who received oxygen therapy at risk of respiratory complications and/or death. The findings included: Record review of CR #1's admission Record, dated [DATE], revealed a [AGE] year-old female who was admitted to 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-09-28 · 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 observation, record reviews and interviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (CR#1) of five residents reviewed for quality of care. The facility failed to ensure CR#1 received necessary care and treatment for a diabetic foot wound on the 4th toe on his right foot resulting in dry gangrene and bone infection. The facility failed to ensure that no new wounds were acquired at the facility. The 1st right toe, left ischium and left buttock wounds were acquired at the facility. CR#1 was admitted to the ER at local hospital on 9/15/2023 after the Wound care Physician B completed an assessment and found that his wounds were worse than documented by Wound Care Physician A. This failure caused CR#1 to be hospitalized and two leg amputations due to the infected wounds and placed the other four residents at risk for wounds worsening, pain and discomfort. An Immediate jeopardy (IJ) situation was identified 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-09-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  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 observation, interview and record review the facility failed to provide care consistent with professional standards of practice promoting healing and prevent new pressure ulcers from developing for 1(CR#1) of 5 residents reviewed for pressure ulcers. The facility failed to ensure that no new pressure wounds were acquired at the facility. The 1st right toe, left ischium and left buttock wounds were acquired at the facility. CR#1 was admitted to the ER at local hospital on 9/15/2023 after the Wound care Physician B completed an assessment and found that his wounds were worse than documented by Wound Care Physician A. This failure caused (CR#1) bone infection and placed other residents at risk for pain, worsening wounds, infection, emotional distress and harm. An Immediate Jeopardy (IJ) situation was identified on 9/25/2023 at 2:03 p.m. While the IJ was removed on 9/27/2023 at 12:52 p.m., the facility remained out of compliance at a scope of pattern with actual harm due to the facility's need to evaluate…

  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 · E2026-06-30 · tag F0814 — failed to dispose of garbage properly — pattern
  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 to dispose of garbage and refuse properly for 2 of 2 dumpsters reviewed for garbage disposal. -The facility failed to ensure one dumpster door and surrounding gate were secured. -The facility failed to ensure one dumpster was emptied and not overflowing. -The facility failed to clean the areas around both dumpsters. These failures could place residents at risk of infection, and potential exposure to vermin and pests from improperly disposed of garbage. Findings include: Observation on 06/30/2026 at 3:32 pm, revealed an open white and metal gate that exposed a green garbage dumpster with the door open. There were two large blue plastic barrels that were uncovered and had clear plastic bags inside that appeared to contain linens. There was a variety of trash on the ground around and directly in front of the dumpster and a broken white PVC shower chair. Just outside of the open white and metal gate there was a dilapidated red shed that did not appear to have a door and was open and exposed from the front. There was…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-22 · 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 observation, interview, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 14 residents (Resident#1) reviewed for accuracy of assessments. The facility failed to ensure Resident#1's admission MDS assessment accurately reflected her gastrostomy tube status. This failure could place residents at risk of receiving inadequate care and services. The findings include: Record review of Resident #1's admission record, dated 04/17/2026, revealed a-[AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Wernicke's encephalopathy (an acute life-threatening neurological emergency caused by a severe deficiency of thiamine [vitamin B1] which damages the brain), aneurysm ( a rare, localized, blood-filled bulge in the wall of carotid artery [major blood vessel located on either side of the neck, that supplies oxygen rich blood to the brain, neck and face] and can cause stroke like symptoms), dysphagia (difficulty…

  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 before2026-04-22 · 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 to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet resident's medical, nursing, mental, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 14 residents (Resident #1) reviewed for care plans. 1. The facility failed to develop or implement a care plan for Resident #1 to address the resident's gastrostomy tube status. 2. The facility failed to develop or implement a care plan for Resident #1 to address the residents' diet. These failures could place residents at risk of not receiving care and services tailored to their identified needs. Findings include: Record review of Resident #1's admission record, dated 04/17/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Wernicke's encephalopathy (an acute…

  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 · D2026-04-02 · 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

  Based on interview and record review , the facility failed to report the results of an investigation in accordance with State Law including the State Survey Agency within 5 working days of the incident for 2 of 2 (Resident #1 and Resident #2) incidents reviewed for reporting. The facility failed to ensure the Administrator reported the results of an investigation within 5 days to the State Survey Agency. This failure could place residents at risk if appropriate corrective actions are not taken. Record review completed on 03/31/2026 at 12:13 p.m., of the TULIP system revealed that a PIR, Form 3613-A, was not filed in the system for two separate incidents reported by the facility on 3/18/2026 to the Complaint and Incident Intake.During an interview on 4/2/2026 at 9:56 a.m., the Director of Operations stated his team was trying to locate the PIRs, but the former administrator may have shredded them. The Director of Operations stated his company acquired the facility the day before on 4/1/2026. During an interview on 4/2/2026 at 10:37 a.m., the Administrator stated her first day 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 · E2026-03-18 · tag F0726 — failed to have competent, trained nursing staff — pattern
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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 have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety for 3 of 6 (Resident #1, Resident #2, and Resident #3) residents reviewed for staffing, in that:The facility failed to ensure RN K's control count sheet for Resident #1 matched the actual Lacosamide, and Resident #2's tramadol blister packet seal was broken and exposed.The facility failed to ensure LVN J's control count sheet for Resident #3 matched Acetaminophen-COD#3 in the blister packet.These failures could place residents at risk of not being provided care by nursing staff with sufficient skills/training.Findings included:Resident #1Record review of Resident #1's face sheet dated 3/18/25 revealed he was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: convulsions (sudden uncontrollable shaking or jerking 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-03-18 · 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 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 and a system of medication records that enables periodic accurate reconciliation and accounting of all controlled medications to meet the needs of 3 of 6 residents (Resident #1, Resident #2, and Resident #3) reviewed for pharmacy services, in that: The facility failed to ensure RN K control count sheet for Resident #1 matched with the actual Lacosamide. The facility failed to ensure Resident #2's tramadol blister packet seal was not broken and exposed. The facility failed to ensure LVN J control count sheet for Resident #3 matched Acetaminophen-COD#3 in the blister packet. This failure could place residents at risk of not receiving their adequate dose of medication and drug diversion. Findings include:Resident #1Record review of Resident #1's face sheet dated 3/18/25 revealed she was a [AGE]…

  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 · Dcited before2026-03-18 · 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 interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical, mental, and psychosocial needs for 1 (Resident #1) of 5 residents reviewed for comprehensive care plans.The facility failed to ensure Resident #1's care plan was not cancelled on 01/19/26.This failure could have placed residents at risk of his needs not being monitored and cared for at the facility.Findings included:Resident #1Record review of Resident #1's face sheet dated 3/18/25 revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: convulsions (sudden uncontrollable shaking or jerking of the body), hypertension (high blood pressure), and traumatic brain injury (damage to the brain caused by an external force).Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 03 of 15, indicating severely impaired 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-18 · 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 control program designed to prevent the development and transmission of infection for 1 of 4 residents (Resident #4) observed for infection control.The facility failed to ensure LVN J followed appropriate infection control procedures while counting prefilled morphine syringes for Resident #4.This failure could have placed the residents at risk for infection.Findings included:Record review of Resident #4's face sheet dated 3/18/25 revealed she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included: diabetes mellitus (high blood sugar), hypertension (high blood pressure), and cerebral infarction (when a blood vessel in the brain was blocked, cutting oxygen to the brain).Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 of 15, indicating severely impaired cognition. Further review 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-11-25 · tag F0838 — failed to assess facility resources and resident needs — widespread
  Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to ensure the facility assessments were documented and facility-wide assessments determined what resources were necessary to care for residents competently during both day-to-day operations and emergencies for 1 of 1 facility (Facility) reviewed for facility assessment. The facility failed to ensure the facility assessment contained information regarding the level of staff needed to meet the needs of each resident. This failure could place residents at risk of inadequate care or treatment. Findings include: Record review of the facility assessment, dated 4/30/25, revealed it did not include information regarding the level of staff needed to meet the needs of each resident. In an interview on 10/29/25 at 3:52pm, the Administrator said he was unsure if the facility assessment included the level of staff needed. He said they did not use the facility assessment when creating the nursing staff schedule. He said they used the facility's PPD and census. He said he made sure the ratio of CNAs to residents was 1:15. He said if they…

  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 · E2025-11-25 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  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 have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility's assessment tool for 3 of 7 residents (Residents #1, #2 and #4) reviewed for sufficient staff. The facility failed to have adequate staff to provide appropriate care to residents, resulting in Resident #1 sitting in a urine-soaked brief during the 2pm-10pm on 10/11/25, Resident #2 staying in bed against his preferences on 10/25/25 during the 6am-2pm and 2pm-10pm shift, and Resident #4 experiencing long waiting times after pushing their call light when they need assistance with incontinent care. This failure could place residents at risk of skin breakdown, loss of independence and…

  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.

Fines & penalties

$272,498 in federal fines across 5 penalties. 2 Medicare payment denials on record.

• $70,637 — penalty dated 2026-06-15
• $58,025 — penalty dated 2026-03-18
• $17,000 — penalty dated 2024-03-08
• $39,693 — penalty dated 2024-03-08
• $87,143 — penalty dated 2023-09-28
• Medicare payment denial — starting 2024-04-06 for 25 days
• Medicare payment denial — starting 2023-10-27 for 31 days

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 CASCADES HEALTHCARE — 19 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 →

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

The source lists no ownership percentage for any party here — 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.

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX