No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

La Bahia Nursing & Rehabilitation

225 E Ward St, Goliad, TX 77963 · For profit - Corporation · 90 certified beds · (361) 645-8902 Medicare & Medicaid certified

Call the home — (361) 645-8902 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609) — most recent May 2024
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1407 W Red River St · (361) 570-7600 · Call to confirm hours
Pharmacy
208 S Commercial St · (361) 645-3261 · Call to confirm hours
Grocery
400 W Pearl St · (361) 645-3364 · Call to confirm hours
Park
Goliad State Park Goliad Tx · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 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 rating4★
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 increased15.6%15.8%15.4%typical
Long-stay residents who lose too much weight0.0%3.0%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.1%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.9%3.3%3.3%worse
Long-stay residents whose ability to walk worsened7.2%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication5.0%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers3.0%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control12.1%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table0.0%9.6%17.1%check this — see note marked star below the table
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%88.0%79.4%better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

0.27U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.371.02Oct 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

0.47
RN hours/ resident / day
1.26
LPN hours/ resident / day
1.23
Aide hours/ resident / day
2.95
Total nurse hours/ resident / day
0.31
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 90 beds and averages 37.7 residents a day — about 42% occupied, or roughly 52 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 2.95 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.23 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 2.53 hrs/resident/day on weekends vs 3.13 on weekdays — 19% thinner on weekends. RN hours go from 0.53 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

6
deficiencies at the latest standard inspection (2026-02-12)
2
at the previous standard inspection (2024-11-08)

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

Inspection deficiencies

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

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · E2026-02-12 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    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 medication error rate was not 5 percent or greater. The facility had a medication error rate of 17.65%, based on 6 errors out of 34 opportunities, which involved 3 of 6 residents (Residents #5, #25 and #43) and 1 of 4 staff (DON) reviewed for medication administration reviewed for medications errors. The facility failed to ensure the DON administered medications to Residents #5, #25 and #43 timely and according to physician order. This deficient practice could place residents at risk of not receiving therapeutic effects of their medications and possible adverse reactions.The findings include: 1. A record review of Resident #5's admission record, dated 2/12/2026, revealed an admission date of 12/25/2025. Resident #5 had diagnoses which included gastro-esophageal reflux disease (GERD a chronic, severe form of acid reflux that occurs when stomach contents frequently flow back into the esophagus) and bronchitis (the inflammation…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-12 · tag F0880 — failed to prevent and control infections — pattern
    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 3 of 8 residents (Residents #10, #22 and #36) and 1 of 1 facility (the facility) reviewed for infection prevention and control measures. 1. The facility failed to ensure CNA C cleaned the urinary collection tube from Resident #10s indwelling catheter.2. The facility failed to ensure CNA C did not place Resident #10's urinary collection bag on the bed and on the floor.3. The facility failed to ensure CNA B followed infection control protocols while delivering Resident #22 and Resident #36's lunch meals. 4. The facility failed to ensure there was a physical barrier between the dirty laundry area and the clean laundry area. 5. The facility failed to ensure clean mops, rags, and new linens were stored in the dirty…

    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 · D2026-02-12 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 interviews and record review, the facility failed to ensure within 14 days after a facility completed a resident's assessment, the facility electronically transmitted encoded, accurate, and complete MDS data to the CMS System upon a resident's transfer, reentry, discharge, and death, for 1 of 8 residents (Resident #4) reviewed for transmitted MDS data to the CMS System.The facility failed to transmit a discharge MDS assessment to the CMS system for Resident #4.This deficient practice could place residents at risk of MDS inaccuracies.Record review of Resident #4's admission Record dated [DATE] documented a [AGE] year-old male who was originally admitted to the facility [DATE] and most recently admitted on [DATE]. The diagnoses for Resident #4 included alcoholic cirrhosis of liver with ascites (liver disease with accumulation of fluid in the abdominal cavity), Type 2 diabetes mellitus with diabetic neuropathic arthropathy (a severe complication of diabetes where nerve damage leads to progressive,…

    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 · D2026-02-12 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care and was developed within 48 hours of a resident's admission for 1 of 8 residents (Resident #10 reviewed for baseline care plans. 1. The facility failed to ensure Resident #10's baseline care plan reflected the residents immediate need for support with an indwelling urinary catheter.2. The facility failed to ensure Resident #10's baseline care plan was developed within 48 hours of admission. These failures could place residents at risk of a decline in health status.The findings include: A record review of Resident #10's admission record, dated 2/12/2026, revealed an admission date of 10/10/2024. Resident #10 had diagnoses which included hemiplegia and hemiparesis affecting the right side (result from damage to the left hemisphere of 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-12 · 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 observation, interview and record review the facility failed to ensure the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 8 residents (Resident #9) reviewed for care plans. The facility failed to ensure Resident #9's prescribed diet for a regular diet texture with finger foods and ground textured meats, were reflected in the residents care plan. This failure could place residents at risk for a decline in their health status.The findings include:A record review of Resident #9's admission record, dated 2/10/2026, revealed an admission date of 12/20/2025. Resident #9 had diagnoses which included Parkinson's disease (a progressive, neurodegenerative brain disorder caused by the loss of dopamine-producing neurons, leading to motor symptoms like tremors, stiffness, bradykinesia [slowness of movement], and walking/balance issues), functional quadriplegia (a condition of complete…

    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 before2026-02-12 · 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 was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 8 residents (Resident #10) reviewed for urinary catheter care. The facility failed to ensure CNA C performed urinary catheter care for Resident #10 according to professional standards. This failure could place residents at risk for a decline in health status.The findings include: A record review of Resident #10's admission record, dated 2/12/2026, revealed an admission date of 10/10/2024. Resident #10 had diagnoses which included hemiplegia and hemiparesis affecting the right side (result from damage to the left hemisphere of the brain, often due to stroke, tumors, or injury. Causing reduced motor control, strength, and mobility in the right arm, leg, and sometimes face), retention of urine (not all the urine is expelled), and history of urinary tract…

    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 · D2024-11-08 · 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 Observations, Interviews, and Record review, the facility failed to ensure that residents had the right to reside and receive services in the facility 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 1 of 3 residents (Resident #22) reviewed for reasonable accommodation of resident needs and preferences, in that: The facility failed to ensure Resident #22's call light was within reach. This failure could place residents at risk of achieving independent functioning, dignity, and well-being. Findings include: Record review of Resident #22's face sheet dated 11/7/24 revealed a [AGE] year old female admitted to the facility on [DATE]. Resident #22 had diagnosis that included Amputation of Bilateral lower extremity (surgical removal of more than one limb), Major Depressive Disorder (a severe mood disorder that can affect a person's thoughts, feelings, and ability to perform daily activities), 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-25 · 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 a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-for 1 of 11 residents (Resident #2) reviewed for care plans, in that: The facility failed to ensure Resident #2's care plan was revised with updated interventions to address 4 of 6 actual falls (01/10/2024, 01/20/2024, 01/29/2024 and 02/08/2024) documented on incident reports and nursing notes. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The Findings included: 1. Record review of Resident #2's face sheet dated 10/22/2024 reflected Resident #2 was admitted on 10 /31/2023 with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-25 · 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 the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 16 residents (Resident #1) reviewed for accident hazards and supervision, in that: On [DATE] CNA A inappropriately transferred Resident #1 with a mechanical lift by herself, which caused a fall resulting in back pain from the mechanical lift support bar hitting her head and landing on the floor. The non-compliance was identified as PNC which began on [DATE] and ended on [DATE]. The facility had corrected the non-compliance before the survey began. This failure could result in residents requiring transfer by a mechanical lift suffering injury, a diminished quality of life, and/or death. The findings were: Record review of Resident #1's face sheet, dated [DATE], reflected a female age [AGE] re-admitted to facility on [DATE] and discharged [DATE] due to death…

    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 · D2024-05-13 · 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 observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused result in serious bodily injury for 1 of 4 Residents (Resident #1) whose records were reviewed for abuse and neglect., in that; The facility failed to report to the state reporting agency (HHSC) an injury of unknown origin when Resident #1 suffered a change of condition and the hospital reported bleeding in the brain and a back fracture. This deficient practice could affect any resident and could contribute to further abuse and neglect. The findings were: Record review of Resident #1's face sheet, dated 5/10/2024 revealed an admission date of 8/03/2023 with diagnoses which included: type 2 diabetes mellitus with diabetic nephropathy (diabetes that causes damage to the kidneys), dementia, and end stage renal disease (severe 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · E2023-10-06 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to implement their written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents for 3 of 26 staff (CNA E, Hskg F, LVN G) reviewed for abuse and neglect, in that: The facility failed to implement their abuse policy when a criminal background check and the EMR was not completed prior to their hire dates for CNA E, Hskg F and LVN G. These deficient practices could place residents at risk for abuse and neglect. The findings were: Record review of facility policy titled Abuse/Neglect, revised 03/29/2018 which read A. Screening: Criminal History and Background Checks. The facility will conduct criminal background checks of all personnel in accordance with Texas Health and Safety Code, Chapter 250. 1. The facility administrator will be responsible for ensuring compliance with the policy and Texas state law regarding criminal background checks. 2. All potential employees will be screened for history of abuse, neglect, or mistreating of elderly/individuals as defined by the applicable…

    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 · E2023-10-06 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to conduct a performance review at least once every 12 months and provide regular in-service education based on the outcome of these reviews for 5 of 7 CNA's (CNA B, CNA C, CNA D, CNA H and CNA J) reviewed for performance reviews, in that: The facility failed to conduct performance reviews at least every 12 months for CNA B, CNA C, CNA D, CNA H and CNA J This failure could result in residents not receiving the necessary care and services due to nurse aides not receiving training based on their performance review outcome. The findings were: 1. Record review of the Staff Roster, dated 10/03/2023, revealed CNA B was hired on 03/01/2021. Record review of CNA B's staff records revealed his last annual performance review was completed on 10/28/2022. 2. Record review of the Staff Roster, dated 10/03/2023, revealed CNA C was hired on 04/01/2021. Record review of CNA C's staff records revealed her last annual performance review was completed on 04/04/2022. 3. Record review of the Staff Roster, dated 10/03/2023, revealed CNA D 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-06 · 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

    Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 1 medication room reviewed for storage, in that: Controlled medications were not kept in a separate, permanently affixed compartment in the medication room. This deficient practice could place residents at risk of misappropriation of medications. The findings were: Observation in the medication room on 10/05/23 at 10:40 AM revealed a miniature fridge with a locked padlock. The front of the fridge was made of tinted glass. Inside the fridge were different insulin pens, too numerous to count, and two 30 ml bottles of lorazepam 2 mg/ml. The controlled medications were not in their own compartment and the miniature fridge was not permanently affixed to the counter it was sitting on. During an interview with the DON on 10/06/2023 at 11:30 a.m., she confirmed there was controlled and not controlled medications mixed in the fridge and not separated. She confirmed the fridge was locked with a padlock but not permanently affixed 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-06 · tag F0806 — failed to honor food preferences — pattern
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 failed to accommodate residents' food preferences for 1 of 17 (Resident #28) residents reviewed in that: The facility failed to ensure Resident #28 received her preference of a lettuce and tomato salad during the lunch meal on 10/03/2023 and her preference of an over easy egg. This failure could affect all residents with food preferences and could result in a decrease in resident choices and diminished interest in meals. The findings were: Record review of Resident #1's face sheet, dated 10/06/2023, reveled the resident was admitted on [DATE] with diagnoses that included: dementia, major depressive disorder, pain in spine, and history of breast cancer. Record review of Resident #1's Quarterly MDS assessment, dated 08/30/2023, revealed a BIMS score of 15, which indicated intact cognitive impairment. Record review of Resident #28's tray card revealed Dislikes: Strawberry; Greens, Turnip; Greens, Mustard. Record review of Resident #28's Dietary Profile, dated…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-06 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Main Kitchen), in that: 1. The facility failed to ensure items in the walk-in refrigerator and dry storage areas were dated and or discarded correctly. These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness. The findings included: 1. During an observation and interview on 10/03/2023 at 11:49 a.m., revealed in reach-in refrigerator #1 a jar of pickles dated with 09/14/2023 but not clearly marked if opened or received; a container of chicken base with a received date of 09/14/2023 and no opened date; a container of minced garlic with no received or opened date; a gallon of teriyaki sauce with two dates 04/08/23 and 10/06/2023 and unable to determine which was the received date and which was the opened date. The DM stated she just put the minced garlic in the refrigerator this morning. During an observation and interview on…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-06 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 5 resident (Resident #17) reviewed for privacy, in that: CNA A and CNA B did not completely close Resident #17's privacy curtain while providing incontinent care for the resident. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #17's face sheet, dated 10/06/2023, revealed an admission date of 08/03/2023, with diagnoses which included: Type 2 diabetes mellitus(high level of sugar in the blood), Dementia(decline in cognitive abilities), Major depressive disorder(mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure) and, End stage renal disease (kidneys no longer work as they should to meet the body's needs). Record review of Resident #17's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 0,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-06 · 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 receives appropriate treatment and services to prevent urinary tract infections for 1 of 2 resident (Resident #15) reviewed for incontinent care, in that: While providing incontinent care for Resident #15, CNA C did not clean between Resident #16's buttocks'' cheeks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #15's face sheet, dated 10/06/2023, revealed an admission date of 05/14/2016 and, a readmission date of 12/06/2019, with diagnoses which included: Cerebrovascular disease (conditions that affect the blood vessels of the brain and the cerebral circulation), Cardiomegaly(enlarged heart), Chronic obstructive pulmonary disease(progressive lung disease characterized by airflow limitation), Major depressive disorder(mental disorder characterized by at least two weeks of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-06 · 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 infection for 1 of 5 residents (Resident #15) reviewed for infection control, in that: CNA D failed to perform hand hygiene or change her gloves after touching the soiled briefs and before touching the clean briefs. This deficient practice could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #15's face sheet, dated 10/06/2023, revealed an admission date of 05/14/2016 and, a readmission date of 12/06/2019, with diagnoses which included: Cerebrovascular disease (conditions that affect the blood vessels of the brain and the cerebral circulation), Cardiomegaly(enlarged heart), Chronic obstructive pulmonary disease(progressive lung disease characterized by…

    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 · D2023-10-06 · tag F0941 — isolated
    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide effective communications mandatory training for 1 of 20 employees (OT Q) reviewed for training, in that: The facility failed to ensure OT Q completed effective communication training. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training. The findings were: Record review of the Staff Roster, dated 10/03/2023, revealed OT Q was hired on 02/20/2020. Record review of OT Q's training history, undated, revealed OT Q had not completed effective communication training since his hire date. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 1:19 p.m., HR stated it was a team effort, from all administration, that was responsible for ensuring staff completed all their required training. She stated their company started using [Website Name] online as of 06/01/2023, which helped keep track of what training certain staff members needed to complete. HR further stated she emailed the supervisor, of the staff member in…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-06 · tag F0944 — isolated
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 2 of 20 employees (CNA D and CNA J) reviewed for training, in that: The facility failed to ensure CNA D and CNA J completed QAPI training since their hired date. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. The Findings were: 1. Record review of the Staff Roster, dated 10/03/2023, revealed CNA D was hired on 03/01/2021. Record review of CNA D 's training history, undated, revealed CNA D had not completed QAPI training since their hired date. 2. Record review of the Staff Roster, dated 10/03/2023, revealed CNA J was hired on 05/06/2021. Record review of CNA J's training history, undated, revealed CNA J had not completed QAPI training since their hired date. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 1:19 p.m., HR stated it was a team…

    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 · D2023-10-06 · tag F0949 — failed to train staff on dementia and abuse — isolated
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for 2 of 20 employees (CNA I and LVN O) reviewed for training, in that: The facility failed to ensure CNA I and LVN O completed behavioral health training since their hired date. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. The findings were: 1. Record review of the Staff Roster, dated 10/03/2023, revealed CNA I was hired on 01/26/2022. Record review of CNA I 's training history, undated, revealed CNA I had not completed behavioral health training since their hired date. 2. Record review of the Staff Roster, dated 10/03/2023, revealed LVN O was hired on 007/01/2022. Record review of LVN O 's training history, undated, revealed LVN O had not completed behavioral health training since their hired date. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 1:19 p.m., HR stated it was a team…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-11-08 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed a to dispose of garbage and refuse properly for 1 of 2 garbage dumpsters (dumpsters #1 and #2) reviewed for disposal of garbage. 1. The facility failed to ensure garbage dumpster #1's lid was completely shut. This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings inclulded: 1. Observation on 11/7/24 at 11:05am with the Dietary Director revealed that one of two garbage dumpsters (dumpster #1) had a 3 x 5 foot lid that was completely open exposing the garbage inside of the dumpster. During an interview on 11/7/24 at 11:10 a.m., with the Dietary Director she stated that having an open lid to the garbage dumpster would allow pests access to the garbage and possibly the facility. The Dietary Director stated that she does train her staff on the necessity of keeping the garbage dumpster lid closed at all times. During an interview on 11/7/24 at 11:45 a.m., with the Administrator she stated that having a garbage dumpster lid open would create 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.

    Nutrition and Dietary 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

No federal fines in the current CMS record.

Part of a chain

This home belongs to CREATIVE SOLUTIONS IN HEALTHCARE — 149 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 5 of 52.1+2.9 vs chain
Health inspection 4 of 52.7+1.3 vs chain
Staffing 2 of 51.1+0.9 vs chain
Quality measures 5 of 53.2+1.8 vs chain
The other 148 homes this chain runs (chain average 2.1★, per CMS)
1 of 5Afton Oaks Nursing and Rehabilitation CenterHouston, TX 1 of 5Arlington Heights Health and Rehabilitation CenterFort Worth, TX 1 of 5Beltline Healthcare CenterGarland, TX 1 of 5Bluebonnet Nursing & RehabilitationKarnes City, TX 1 of 5Bluebonnet Point WellnessBullard, TX 1 of 5Brentwood Terrace Healthcare And RehabilitationParis, TX 1 of 5Buena Vida Nursing and Rehab-San AntonioSan Antonio, TX 1 of 5Cottonwood Nursing & RehabilitationDenton, TX 1 of 5Countryview Nursing & RehabilitationTerrell, TX 1 of 5Dogwood Trails ManorWoodville, TX 1 of 5Downtown Health and Rehabilitation CenterFort Worth, TX 1 of 5Estates Healthcare and Rehabilitation CenterFort Worth, TX 1 of 5Fair Park Health & Rehabilitation CenterDallas, TX 1 of 5Five Points Nursing & Rehabilitation of College StCollege Station, TX 1 of 5Five Points at Lake Highlands Nursing and RehabDallas, TX 1 of 5Five Points of PflugervillePflugerville, TX 1 of 5Franklin Heights Nursing & RehabilitationEl Paso, TX 1 of 5Gilmer Nursing & RehabilitationGilmer, TX 1 of 5Grace Pointe Wellness CenterEl Paso, TX 1 of 5Graham Oaks Care CenterGraham, TX 1 of 5Granbury Care CenterGranbury, TX 1 of 5Greenhill VillasMount Pleasant, TX 1 of 5Heritage At Longview Healthcare CenterLongview, TX 1 of 5Huebner Creek Health & Rehabilitation CenterSan Antonio, TX 1 of 5Interlochen Health and Rehabilitation CenterArlington, TX 1 of 5Kenedy Health & RehabilitationKenedy, TX 1 of 5Kennedy Health & RehabLufkin, TX 1 of 5Lake Lodge Nursing & RehabilitationLake Worth, TX 1 of 5Lampstand Nursing and RehabilitationBryan, TX 1 of 5Lancaster Nursing & RehabilitationLancaster, TX 1 of 5Marine Creek Nursing & RehabilitationFort Worth, TX 1 of 5Mesa Vista Inn Health CenterSan Antonio, TX 1 of 5Mountain View Health & RehabilitationEl Paso, TX 1 of 5Navasota Nursing & RehabilitationNavasota, TX 1 of 5Normandy Terrace Nursing & Rehabilitation CenterSan Antonio, TX 1 of 5North Pointe Nursing and RehabilitationWatauga, TX 1 of 5Park Place Care CenterGeorgetown, TX 1 of 5Parkview Manor Nursing and RehabilitationWeimar, TX 1 of 5Peach Tree PlaceWeatherford, TX 1 of 5Pebble Creek Nursing CenterEl Paso, TX

Showing 40 of 148; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
HUGGINS, LINDAIndividualW-2 MANAGING EMPLOYEEsince 03/01/2021
CREATIVE SOLUTIONS IN HEALTHCARE INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2021
BLAKE, GARYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2021
BLAKE, MALISAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2021

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.

$3.1M
Net patient revenuemost recent cost report
-26.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 63%Medicare 4%Other / private 32%

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

$261per resident / day
operating cost
$7,927per month
≈ monthly operating cost
$206per 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 675372. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

What to do next