Oakmont Healthcare and Rehabilitation of Humble

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.

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 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 134 beds and averages 63.3 residents a day — about 47% occupied, or roughly 71 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 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 2.85 hrs/resident/day on weekends vs 3.44 on weekdays — 17% thinner on weekends. RN hours go from 0.40 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 91% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

Inspection deficiencies

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

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

32 citations, most serious first. The 19 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · K2024-11-02 · 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 reviews the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 3 of 6 residents (Resident #43, Resident #45, and Resident #7) reviewed for pressure ulcers. - The facility failed to provide daily wound care for Resident #43 on 10/1/24, 10/13/24, 10/21/24, 10/23/24, and 10/27/24, resulting in worsening of his L Heel, R Heel, R Distal (closest to foot) Leg, R Proximal (furthest away from foot) Leg, L Ischium (buttock), and R Ischium (buttock) pressure ulcers. - The facility failed to receive Resident #43's biopsy/culture results for his R heel that was performed 9/30/24, until 10/24/24. - The facility failed to start Resident 43's antibiotic for MRSA and osteomyelitis (bone infection) to his R heel until 10/31/24, when results were received on 10/24/24. - The facility failed to have…

  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 before2024-06-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that the residents' environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #2) of five residents reviewed for accidents hazards and supervision, in that: -Resident #2 fell from lift, sustained a head abrasion and L foot fracture during a Hoyer lift transfer (a device designed to assist caregivers in safely transferring patients or individuals with limited mobility) when CNA K operated the Hoyer lift by herself. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 1/2/24 and ended on 1/3/24. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of injury and hospitalizations. The findings include: Record review of Resident #2's face sheet dated 6/20/24 revealed an [AGE] year-old female who admitted on [DATE].…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · K2023-09-18 · 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 consult with 1 of 16 residents (Resident #8) representatives when there was a significant change in the resident's physical status and a need to alter treatment significantly, in that: - The facility failed to notify Resident #8 family of a PEG tube was deemed non-functional for over 5 months resulting in multiple infections at the site of the G-tube and the resident was ultimately hospitalized when Resident #8's tube became dislodged and caused a partial bowel obstruction. - Resident #8 experienced a decline in ADLs as evidenced by downgrade from Regular heart healthy pureed diet to enteral feeds after tube replacement post- partial bowel obstruction. An Immediate Jeopardy (IJ) was identified on 09/08/23 at 4:05PM. While the IJ was removed on 09/12/23 at 06:25 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness…

  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 · K2023-09-18 · tag F0658 — failed to meet professional standards of care — pattern
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 2 of 5 residents (CR #19 and Resident #317) reviewed for professional standards. - The facility failed to ensure RN C administered Glucagon, an injectable hormone used to raise blood sugars, to CR #19 when he suffered from a BS of 62. - The facility failed to ensure RN C sent CR #19 through immediate emergency transport after being diagnoses with critical vitals. - The facility failed to ensure RN C administered Naloxone, a medication used to treat opioid overdose, when Resident #317 experienced an opioid overdose. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of Pattern and a severity level of actual harm due to the facility continuing need to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk for hypoglycemia, drug overdose, decline…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-09-18 · 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, interview and record review, the facility failed to ensure treatment and care in accordance with professional standards of practice provided to 3 of 16 residents, (CR #19, Resident #1 and Resident #317), reviewed for quality of Care. - The facility failed to ensure RN C administered Glucagon, an injectable hormone used to raise blood sugars, to CR #19 when he suffered from a BS of 62. - The facility failed to ensure RN C sent CR #19 through immediate emergency transport after being diagnoses with critical vitals. - The facility failed to ensure RN C administered Naloxone, a medication used to treat opioid overdose, when Resident #317 experienced an opioid overdose. -The facility failed to reinstate Resident #1's Metformin after readmission to the facility. An Immediate Jeopardy (IJ) was identified on 09/08/23 at 4:05PM. While the IJ was removed on 09/16/23 at 06:25 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-09-18 · 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, for 1 of 6 residents (Resident #8) reviewed for enteral nutrition, the facility failed to ensure whoever was able to eat enough was not fed by enteral methods unless the resident's clinical condition demonstrated that the enteral feeding was clinically indicated and consented to by the resident, in that: - Resident #8 had a PEG tube deemed non-functional for over 5 months without enteral feeds or water flushes. - Resident #8 experienced multiple episodes of infections at her PEG tube site. - The NP convinced Resident #8's RP to not remove PEG tube in case it needed to be used for emergency enteral feedings or medications. She did not communicate resident's complications related to PEG tube or that it was non-functional. - Resident #8 was found on 08/16/2023 with PEG tube pulled out with tip broken off and was hospitalized as a result. - Resident #8 experienced a decline in ADLs as evidenced by downgrade from Regular heart healthy pureed diet to enteral feeds…

  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 · K2023-09-18 · 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 ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 6 staff ( RN C) and 2 of 5 residents ( CR #19 and Resident #317) reviewed for nursing competency. - RN C failed to administer Glucagon, an injectable hormone used to raise blood sugars, to CR #19 when he suffered from a BS of 62. - RN C failed to send CR #19 through 911 emergency transport after being diagnosed with critical vitals. - RN C failed to administer Naloxone, a medication used to treat opioid overdose, when Resident #317 experienced an opioid overdose. An IJ was identified on [DATE] at 09:00 AM. While the IJ was removed on [DATE] at 06:37 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan 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
• Immediate jeopardy · J2023-09-18 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 3 of 12 residents (Resident #62, Resident #217 and Resident #317) reviewed for pain management. - The facility failed to acquire, dispense, and timely administer pain medications and failed to assess Resident #317's pain resulting in pain of 10 out of 10. - The facility failed to assess and document Resident #62 pain accurately or at all. - The facility failed to assess and document Resident #217's pain. An IJ was identified on 09/06/23. The IJ template was provided to the facility on [DATE] at 04:20 PM. While the IJ was removed on 09/11/23 at 1:57 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal These failures could…

  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 · J2023-09-18 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 4 of 10 residents (Resident #24, Resident #54, Resident #61 and Resident #317) reviewed for pharmaceutical services. - The facility failed to acquire, dispense, and timely administer medications to Resident #317 upon admission resulting in pain of 10 out of 10. An IJ was identified on 09/06/23. While the IJ was removed on 09/11/23 at 1:57 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents receiving medication at risk of inadequate therapeutic outcomes and uncontrolled pain. Non-IJ - The facility failed to administer Pantoprazole, a medication used to treat acid reflux,…

  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 before2026-06-11 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  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 review, and interview, the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (Resident # 4) of 5 residents reviewed for quality of care. -Resident #4's right hand splint was not put on in the AM of 06/11/26. This failure could place residents at risk for a decline in movement. The findings included: Record review of Resident #4's admission Record, dated 06/11/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis (hemiplegia is paralysis of one side of the body, while hemiparesis is weakness on one side) following cerebral infarction (ischemic stroke and requiring targeted rehabilitation for recovery) affecting right dominant side, contracture right hand (condition where the muscles in the right hand become tight and stiff, making it difficult to move; this…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-02-26 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for residents, staff, and the public, for 2 of 21 resident rooms (Resident #39 and #28) reviewed for physical environment.The facility failed to maintain clean privacy curtains for Resident #39 and clean bed linen for an unoccupied bed in Resident #28's room.This failure could lead to residents experiencing a diminished quality of life. Findings included:Record review of Resident #39's face sheet dated 02/26/26 revealed a [AGE] year-old admitted to the facility on [DATE]. His diagnoses included stroke, contractures, Hemiplegia (one sided paralysis or severe loss of strength on one side), diabetes (a chronic condition that occurs when blood glucose levels are too high) and peripheral vascular disease (a disorder of blood vessels outside the heart that affects blood flow to the limbs).Record review of Resident #39's quarterly MDS dated [DATE] revealed a BIMS score of 8 out of 15…

  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 · Ecited before2026-02-26 · 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 the medication error rate was not five percent or greater. The facility had a medication error rate of 19%, based on 5 errors out of 26 opportunities, which involved 2 of 6 residents (Resident #26 and #28) and 2 of 4 staff (LVN J and LVN D) observed during medication administration reviewed for medication errors.LVN J administered insulin to Resident #26 at the incorrect time according to the facility MAR.LVN D failed to flush with water between medications during g-tube administration for Resident #28.These failures could place residents at risk of not receiving the desired therapeutic effect of their medications.Findings include:Resident #26Record review of Resident #26's admission record dated 2/26/26 revealed a [AGE] year-old male who admitted on [DATE]. His diagnoses included type 2 diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels), hyperglycemia (high blood sugar), and moderate…

  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 before2026-02-26 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights set forth to attain or maintain the residents highest practicable physical, mental, and psychosocial needs and well-being for 1 of 14 (Resident #69) residents.The facility failed to ensure that Resident #69's care plan documented interventions for hand contractures.This failure could result in residents being at risk and not receiving proper care.Findings included:Record review of Resident #69's undated admission record revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included multiple sclerosis (long lasting disease or central nervous system), tremor, muscle weakness, lack of coordination (muscle control problem), mild cognitive impairment, and muscle spasm.Record review of Resident #69's SBAR Assessments for dates ranging 07/16/2024-02/23/2026 did not reveal a change…

  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 before2026-02-26 · 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 Number of residents sampled: Number of residents cited: Based on interviews, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision for 1 (Residents #71) of five residents reviewed for accidents and hazards.The facility failed to ensure that Resident #71's face was not pressed against the nightstand while she was getting incontinent care. This failure could place residents at risk of injury. Findings included:Record review of a face sheet dated 2/25/2026 indicated Resident #71 was a [AGE] year-old female who admitted on [DATE] with diagnoses including Type 2 Diabetes, Hypermetropia, farsighted, Age-Related Nuclear Cataract, Bilateral (A Major cause of blindness), Dementia, Major depressive disorder, Anxiety disorder, Heart Failure, and Edema (Swelling caused by excess fluid trapped in the body's tissues).Record review of the comprehensive care plan dated 01/07/2026 indicated Resident…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of three (Resident #6) residents reviewed for respiratory care.The facility failed to ensure Resident #6's oxygen was administered at the prescribed setting.These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included:Record review of Resident #6's face sheet dated 02/25/26 revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. Resident #6's diagnoses included progressive supranuclear ophthalmoplegia (a rare neurological disorder characterized by the gradual loss of voluntary eye movement), chronic respiratory failure with hypoxia (a long-term condition…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-01-28 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  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 with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (Resident #1) of 5 residents reviewed for range of motion.The facility failed to ensure Resident #1's leg and hand splint was offered and applied according to MD orders.This failure could result in worsening of contractures and ADL decline.Findings include:Record review of Resident #1's admission record dated 1/28/26 revealed a [AGE] year-old male who admitted on [DATE]. His diagnoses included cerebral infarction (stroke), contracture, left knee (onset: 7/2/25; contracture is a permanent shortening producing deformity or distortion), hemiplegia (one-sided paralysis or weakness) affecting left nondominant side, and cognitive communication deficit.Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15 which…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-28 · 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 implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #1) of 5 residents reviewed for comprehensive care plans.The facility failed to ensure Resident #1's fall mat was in place on 1/28/26 according to the care plan. The facility failed to ensure Resident #1 was changed with 2 people instead of 1 on 1/28/26 as indicated in the care plan. The facility failed to check Resident #1's brief every 2 hours on 1/28/26 as indicated in the care plan. These failures could place residents at risk of not being cared for according to their wishes and specialized care plan.Findings include: Record review of Resident #1's admission record dated 1/28/26 revealed 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-09-18 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents have the right to a safe, clean comfortable, and home like environment, including but not limited to receiving treatment and supports for daily living safely for residents, staff and the public for 3 of 4 days (09/15/2025, 09/16/2025, 09/18/2025) for 2 (Resident #2 and Resident #7) of 21 residents.The facility failed to maintain a clean and sanitary environment in resident rooms, specifically regarding the cleanliness of the floors.This failure could place risk for the residents by slipping, tripping, pest attraction, or infection control.Findings include:Record review of Resident #2's undated face sheet revealed he was a [AGE] year-old male with an initial admission date of, 03/20/2025. Resident #2 had diagnosis of, other lack of coordination, need assistance with personal care, epilepsy-unspecified not intractable without status epilepticus (a seizure within 5 minutes), gastro-esophageal reflux disease without…

  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 · D2025-07-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  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 unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 1 (Resident# 1) of 6 residents reviewed for activities of daily living in that: The facility failed to provide mouth care to Resident #1 on 6/24/2025. This failure placed residents who need assistance with ADL at risk for psychological embarrassment, sadness, and decrease in quality of life. Record review of Resident #1's face sheet dated 07/10/25 revealed a [AGE] year-old female who was admitted to the facility initially on 02/25/2021 and readmitted on [DATE]. The resident's diagnoses included the following: Alzheimer's Disease (a disease that destroys memory and other important memory function), muscle weakness (decreased strength in the muscle), lack of coordination (impaired balance), hypertension (high blood pressure) constipation (difficulty having bowel movement) hyperlipidemia…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$418,615 in federal fines across 3 penalties. 3 Medicare payment denials on record.

• $212,652 — penalty dated 2024-11-02
• $13,627 — penalty dated 2024-06-07
• $192,336 — penalty dated 2023-09-18
• Medicare payment denial — starting 2024-12-03 for 45 days
• Medicare payment denial — starting 2024-02-06 for 30 days
• Medicare payment denial — starting 2023-10-21 for 33 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 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 →

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

CMS files one row per role, so the 11 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in TX