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Lone Star Ranch Rehabilitation and Healthcare Cent

316 General Cavazos Blvd, Kingsville, TX 78363 · For profit - Corporation · 146 certified beds · (410) 552-4800 Medicare & Medicaid certified

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Flagged for abuse1 actual-harm citation$8,190 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,190 in federal fines (most recent 2023-09-18)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1311 E General Cavazos Blvd Ste L · (361) 221-1087 · Call to confirm hours
Pharmacy
1133 General Cavazos Blvd · (361) 595-5429 · Call to confirm hours
Grocery
1133 E General Cavazos Blvd · (361) 595-4146 · Call to confirm hours
Park
501 Santiago park lane · Typically dawn to dusk
Place of worship
2200 S 6th St · (361) 522-3815

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 4 of 5
Short-stay residentsrehab / post-hospital 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 3 to 2 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 rating2★
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 increased23.9%15.8%15.4%worse
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 symptoms0.0%2.4%6.5%check this — see note marked star 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 injury4.0%3.3%3.3%worse
Long-stay residents whose ability to walk worsened19.1%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication22.2%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers0.5%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control13.1%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.1%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine88.9%88.0%79.4%better
Short-stay residents rehospitalized after admission5.4%25.7%22.6%better
Short-stay residents with an outpatient ER visit4.1%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days3.742.171.67worse
Long-stay outpatient ER visits per 1,000 resident days1.422.061.80better

* 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.

50.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.0%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
0.30U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% 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 SNF50.0%CMS range 36.0–63.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 7.6–17.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.7%CMS range 4.5–13.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.901.02Oct 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

0.64
RN hours/ resident / day
0.56
LPN hours/ resident / day
2.02
Aide hours/ resident / day
3.22
Total nurse hours/ resident / day
0.50
RN hoursweekends
43.8%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 146 beds and averages 82.7 residents a day — about 57% occupied, or roughly 63 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 3.22 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.37 on weekdays — 16% thinner on weekends. RN hours go from 0.70 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

3
deficiencies at the latest standard inspection (2025-06-19)
4
at the previous standard inspection (2024-04-25)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2023-09-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1 of 1 resident (R#2) reviewed for accidents. The facility failed to provide R #2 with adequate supervision, resulting in falls on 08/13/23 and 08/17/23. This failure could lead to the injury of residents that are at risk of falls. The findings included: Record review of R #2 's file reflected a [AGE] year-old female, with an original admission date of 08/11/23. Her diagnoses included: unspecified fracture of upper end of left humerus (upper arm bone), muscle wasting and atrophy, other lack of coordination, cognitive communication deficit (difficulties with thinking and how someone uses language), dysphagia (swallowing difficulties), cerebral infarction (stroke), anxiety disorder, and other specified depressive episodes. Record review of R #2's MDS assessment dated [DATE] reflected R#2 had a BIMS score of 12 (moderate cognitive impairment) and required extensive assistance for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-28 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that drugs and biologicals were stored in locked compartments for one of one (wound care) carts observed for storage compliance. The facility failed to ensure the 400-hall wound care cart was left unlocked and unattended by LVN A. This failure could place residents at risk of access and ingestion of medications not intended for resident and drug diversion. Findings were: Observation on 5/28/26, at 10:45 a.m., the 400-hall wound care cart was unlocked parked outside of room [ROOM NUMBER]. The ADON locked the cart when walking by and stated it was the wound cart. During an interview on 5/28/26 at 12:15 p.m., LVN A verbalized she was performing wound care inside a room on the 400 hallway. LVN A stated she did access the wound cart after initially gathering supplies to get more gauze and thought she locked the cart. LVN A stated it is policy and procedure to lock all carts, including the wound care cart. LVN A stated a resident 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to protect Resident #1's right to be free from physical abuse when Resident #2 hit Resident #1 on the right arm, twice, on 12/10/2025. This failure could place residents at risk for physical injury.The findings included: 1. Record review of Resident #1's face sheet, dated 12/10/2025, revealed a [AGE] year-old female with an original admission date of 02/14/2018, and a current admission date of 10/28/2025. Resident #1's diagnoses included Dementia (a condition which affects memory, thinking, and the ability to perform daily activities), Alzheimer's Disease (a progressive disorder which was the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), and Cognitive Communication Deficit (difficulties in communication which arise from impaired cognitive…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-29 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 4 treatment and medication carts (main treatment cart) reviewed for labeling and storage. The facility failed to ensure the main treatment cart belonging to RN-A was locked and secured. This failure could place the residents at risk of gaining access to unlocked medical supplies and medications which were not prescribed to them and could cause them harm.The findings included: Observation on 12/29/2025 at 8:19 AM revealed an unlocked treatment cart belonging to RN-A parked in the A Hall with no nurses or other staff around it. RN-A was in a room with a resident. There were residents noted to be ambulating in and down the halls. The main treatment cart lock was popped out, and all drawers were able to be opened and accessed. The main treatment cart was full of treatment supplies and treatment medications, to include scissors, needles, multiple containers of liquids, as well as a medication cup filled with a thick, white substance 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-26 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #1 and Resident #2) of 2 residents reviewed for medical records.LVN A failed to document a verbal and physical altercation on 10/08/25 between Resident #1 and Resident #2 in a timely manner in Resident #1's progress notes.LVN A failed to document a verbal and physical altercation on 10/08/25 between Resident #1 and Resident #2 in a timely manner in Resident #2's progress notes.LVN B failed to document injury assessments on Resident #1 in a timely manner.RN C failed to document injury assessments on Resident #1 in a timely manner. These failures could put residents at risk of improper care based on inaccurate or incomplete documentation.Record review of Resident #1's admission record reflected a [AGE] year-old male admitted to the facility on [DATE]. His relevant diagnoses included…

    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 before2025-06-19 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews 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, and 2 of 2 nutrition rooms reviewed for storage, preparation, and sanitation. The facility failed to ensure the ice machine chute was clean. The facility failed to ensure the juice gun nozzle was clean. The facility failed to ensure the steam table wells were clean. The facility failed to ensure the underside of the shelf directly above the range was clean. The facility failed to ensure containers of spices were not left open to air. The facility failed to ensure items in the dry storage area were sealed properly. The facility failed to ensure items in the refrigerators were labeled and dated. The facility failed to ensure food in the walk-in freezer were sealed properly. The facility failed to ensure there were no personal items in the walk-in freezer. The facility failed to ensure the cleaning schedule was…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review the facility failed to ensure the medication error rate was not five percent or greater. The facility had a medication error rate of 7.41% based on 2 errors out of 27 opportunities, which involved 2 of 4 residents (Resident #45 and Resident #133) reviewed for medication errors. - LVN C failed to administer medication as ordered to Resident #45 by administering only one 400 mcg tablet of folic acid (Vitamin B-9, important in red blood cell formation and cell growth) instead of 800 mcg as ordered. - LVN C failed to administer medication as ordered to Resident #133 by holding one 12.5 mg tablet of hydrochlorothiazide (diuretic that lowers blood pressure as well as treat fluid retention) despite an active order to administer it. These failures could place residents receiving medication at risk of inadequate therapeutic outcomes. The findings included: 1. During an observation on 06/18/25 at 8:25 AM, LVN C prepared medications for Resident #45 during medication pass. LVN C only gathered one 400 mcg tablet of folic acid from the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-19 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 (100-hall nurse cart) medication carts reviewed for medication storage. 1. The facility failed to write the open date on the vial of Resident #10's multidose Lantus insulin vial in the 100-hall nurse cart. 2. The facility failed to write the open date on the vial of Resident #133's multidose Lispro insulin vial in the 100-hall nurse cart. This deficient practice could place residents at risk of receiving expired insulin. The findings included: 1. Record review of Resident #10's face sheet dated [DATE] revealed a [AGE] year-old female with an admission date of [DATE]. Pertinent diagnosis included Type 2 Diabetes Mellitus (chronic condition where the body either doesn't produce enough insulin or…

    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 before2025-05-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure the right to be free from abuse for two (Residents #2 and #3) of 4 residents reviewed for abuse. The facility failed to ensure Resident #2 was free from abuse. On 05/09/25, Resident #1 slapped Resident #2 in the face twice with an open hand because Resident #2 would not give Resident #1 her napkin. The facility failed to ensure Resident #3 was free from abuse. On 05/10/25, Resident #1 grabbed Resident #3 ' s arm and slapped it four times with an open hand, once with each word, while she said, I told you so. This failure could place residents at risk for abuse and psychological harm. Findings included: Record review of Resident #1's face sheet dated 06/27/22 with an original admission date of 03/18/22 revealed a [AGE] year-old female with diagnoses including Alzheimer ' s, (disease that results in loss of memory, language problem, problem-solving and other thinking abilities that are severe enough to interfere with daily life),…

    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 · Dcited before2024-11-12 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that drugs and biologicals were stored in locked compartments for 1 of 4 medication carts observed for compliance. Medication cart #1 was left outside of room [ROOM NUMBER] unlocked and unattended by RN A. This failure could place residents at risk of access and ingestion of non-narcotic medications. This failure had the potential to affect 5 residents in this hall. Findings were: During an observation on 11/7/2024, at 8:39 a.m., Medication cart #1 unlocked on hall 400 without a supervised staff in view of the cart. The cart was unlocked for 5 minutes until RN A was questioned about the unlocked cart. During an interview on 11/7/2024 at 10:45 a.m., RN A verbalized the unlocked cart was her cart. She verbalized she must have forgot to lock the cart after giving her last medication. RN A stated it was proper process to lock the cart when the cart was not in view or when not being used. She also stated a resident could have accessed 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 · Fcited before2024-04-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to ensure dry goods were sealed 2. The facility failed to ensure dry goods were labeled and dated 3. The facility failed to ensure equipment was clean and sanitized 4. The facility failed to refrain from having personal items in the prep areas 5. The facility failed to label and date items in the walk-in refrigerator 6. The facility failed to label and date items in the walk-in freezer 7. The facility failed to maintain temperature logs for refrigerators and the freezer 8. The facility failed to maintain temperature and sanitization logs for the 3-compartment sink 9. The facility failed to maintain proper lighting in the walk-in refrigerator 10. The facility failed to maintain the door latch in walk-in freezer These failures could place residents at risk of foodborne illnesses. Findings included: Observation and initial tour of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · E2024-04-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that respiratory care was provided, consistent with professional standards of practice, for 3 Residents (Resident #21, Resident #23, and Resident #170) of 6 residents reviewed for respiratory care and services, in that: The facility failed to ensure Resident #21, Resident #23, and Resident #170's oxygen tubing was not dated according to physician's order. This deficient practice could place residents who required oxygen therapy at risk of receiving inadequate respiratory treatments and could result in decline in health. The findings included: 1.) Record review of Resident # 21 face sheet dated 4/25/2024 reflected a [AGE] year-old-female with an original admission date of 2/22/2020. Diagnosis included heart failure, type two diabetes (insufficient production of insulin in the body), and chronic obstructive pulmonary disease (chronic obstructed airflow from the lungs). Record review of Resident #21's MDS dated [DATE] reflected a BIM…

    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 before2024-04-25 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide separately locked and permanently affixed compartments for Schedule II-V medications and/or other medications subject to abuse in two (B and C wing) of two medication rooms that contained emergency use narcotics boxes. The facility failed to ensure the emergency use narcotic boxes in B and C wing medication rooms were permanently affixed. These failures could place residents at risk for misappropriation and/or diversion of medication. Findings included: Observation on [DATE] at 10:20 AM, the medication storage room on the secured memory unit C wing revealed a key locked door into the medication room. LPN A had the key and unlocked the door. Inside the medication room, there was a red metal box with a numbered keypad on the front sitting on top of the mini refrigerator. This box was picked up without difficulty and could easily have been carried out of the room. Observation on [DATE] at 11:32 AM, the medication storage room in B…

    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 before2024-04-25 · 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, record review, and interview, 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 2 (Resident #2 and Resident # 122) of 5 residents and 4 of ( CNA C, CNA D, CNA E, and HA F) staff that were reviewed for infection control in that: 1. CNA C and CNA D did not perform hand hygiene for 20 seconds or longer and did not remove contaminated gloves during peri care after changing Resident # 2's brief and prior to putting on a new brief. 2. CNA E and Hospitality Aide F did not perform hand hygiene prior to peri care and did not perform hand hygiene for 20 seconds or longer after peri care. CNA E and Hospitality Aide E did not remove contaminated gloves during peri care after changing Resident #122's brief and prior to putting on a new brief. These failures could place residents at risk for infection…

    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 · Dcited before2023-09-18 · tag F0607 — failed to have anti-abuse policies — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse and neglect for 1 of 1 resident #2 (R #2) reviewed for incident reporting. The facility failed to report an allegation of neglect for R #2 for an incident on 08/13/23 and failed to report an allegation of neglect for R #2 within the required timeframe of the incident on 08/17/23. This failure could place residents at risk of abuse, neglect, and not having incidents reported appropriately. The findings included: Abuse Prohibition Policy (revised 10/2022) Reporting/Response: The facility will report all allegations and substantiated occurrences of abuse, neglect, misappropriation of resident property to the state agency and to all other agencies are required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily…

    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 · D2023-09-18 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were reported immediately to the State Survey Agency, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 1 resident (R #2) reviewed for abuse/neglect. The facility failed to report allegations of resident neglect for R #2 for incidents on 08/13/23 and 08/17/23 to the State Survey Agency within the allotted time frame (incident on 08/17/23 was at around 12:05 PM and it was reported until 08/18/23 at 8:55 AM). This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse and neglect. The findings included: Record review of Provider Investigation dated 08/28/23 reflected date and time reported to HHSC on 08/18/23 at 8:55 AM.…

    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 · D2023-09-18 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were investigated for 1 of 1 resident (R #2) reviewed for abuse/neglect. The facility failed to thoroughly investigate alleged violations of neglect after R #2 fell on [DATE] and 08/17/23. This failure could place all residents at increased risk for potential abuse due to uninvestigated allegations of abuse and neglect. The findings included: Record review of R #2 's file reflected a [AGE] year-old female, with an original admission date of 08/11/23. Her diagnoses included: unspecified fracture of upper end of left humerus (upper arm bone), muscle wasting and atrophy, other lack of coordination, cognitive communication deficit (difficulties with thinking and how someone uses language), dysphagia (swallowing difficulties), cerebral infarction (stroke), anxiety disorder, and other specified depressive episodes. Record review of R #2's MDS assessment dated [DATE] reflected R#2…

    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 · Dcited before2023-08-10 · tag F0607 — failed to have anti-abuse policies — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to take appropriate actions during an investigation of an unwitnessed accident in that facility policy required investigations to be prompt, comprehensive and responsive to the situation and contain founded conclusions for 1 of 1 (Resident #1) residents reviewed for incidents/accidents. Resident #1 experienced a fractured right humerus. During the investigation no conclusion was drawn as to how the injury occurred. This incident was reported to the state on 6/17/2023. This failure could affect residents by having unnecessary or inappropriate remedies implemented, or having no appropriate remedies implemented to ensure resident safety. Findings include: Record review of Resident #1's clinical record's face sheet revealed an [AGE] year-old female with the diagnoses of other specified disorders of bone density and structure (unspecified site), Alzheimer's disease, dementia, abnormal gait, humerus fracture. Record review of Resident #1's Care Plan, accessed…

    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 · D2023-08-10 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that include measurable objectives and time frames to meet residents' physical needs for 1 of 1 (Resident #1) residents reviewed for care plans. The facility failed to develop a care plan to address Resident #1's fractured Humerous, which is the largest bone in the upper arm. This failure could affect residents by placing them at risk of not having their needs met. Findings include: Record review of Resident #1's face sheet revealed an 85 y/o female with diagnoses of other specified disorders of bone density and structure (unspecified site), Alzheimer's disease, dementia , abnormal gait, and a Humerus fracture. Record review of Resident #1's Care Plan, accessed on 7/20/2023 at 3:30 PM indicated Resident #1 had limited physical mobility r/t muscle weakness. Interventions revealed Resident #1 was WEIGHT-BEARING with transfers. She…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-10 · 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, record review, and interview, 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 one of (Resident #2) of five residents that were reviewed for infection control and transmission-based precautions policies and practices, in that: NA A did not perform hand hygiene prior to commencement of perineal care. NA A proceeded to clean perineal area without performing hand hygiene and maintained usage of dirty gloves throughout care. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Record review of Resident #2's Face Sheet dated 07/21/2023, admitted originally 03/28/2019, with readmission date, documented a [AGE] year-old female with the following diagnoses of: dementia, cognitive communication deficit, pain, bipolar disorder…

    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 · Ecited before2023-02-23 · 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 by professional standards for food service safety for 1 of 1 kitchen reviewed and 1 of 3 med room nutrition refrigerators in that: The steam table was not clean The shelf on the steam table was not clean The juice gun and rest tray were not clean The ice machine was not clean The refrigerator temperatures were above the required minimum The dishwasher temperatures were below the required minimum There were unlabeled foods in the med room nutrition refrigerator These failures could place residents at serious risk for complications from food contamination, and/or foodborne illness. Findings were: Observations of the kitchen during the initial tour on 02/21/23 at 10:15 AM revealed: The juice gun & rest tray was covered with a thick, sticky-looking substance. The steam table wells had thick, flaking, crusty yellowish, and brown substances in each of the 4 compartments. The shelf above the steam table had a brown substance the entire width of the underside of the shelf,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-02-23 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, and record review, the facility failed to designate a person to serve as director of food and nutrition services who is a qualified dietary manager 1 of 1 facility in that: The facility has been without a certified dietary manager since 10/01/2018. This failure could result in the dietary needs of all residents served by the kitchen not being met. Findings included: Record review of the DM's Personnel file on 02/21/23 revealed that the facility's current Dietary Manager was hired on 10/01/18. The file contained documentation that the Dietary Manager had completed a precertification course on 06/20/20, but contained no other qualifications. An interview with the DM on 02/21/23 at 2:30 PM revealed that she completed her coursework in June 2020. The DM stated she applied for testing for her DM certification in January 2022. The DM stated something happened at the testing center and the program locked up and kicked her out. The DM stated she attempted the test again in August 2022 and failed. The DM provided proof to re-test on 03/15/23. The DM did not respond as to…

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

    Nutrition and Dietary Deficiencies · Past Non-Compliance
  • No harm found · C2023-02-23 · 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 observations, interviews and record review the facility failed to dispose of garbage and refuse properly for 1 of 1 grease traps reviewed in that: The grease trap was not being used Used grease was disposed of via a plastic bag into the dumpster This failure could place residents at risk of infection and vermin from improperly disposed of used grease. The Findings were: Observation and interview with the DM on 2/22/23 at 9:25 AM revealed no grease traps behind the dumpsters. The DM stated the grease traps stored behind the dumpster had been stolen approximately 1 year ago. When asked how used grease was disposed of, the DM stated, we put it in a plastic trash bag and throw it in the dumpster (the DM demonstrated to this surveyor how this was accomplished, simulating water for grease). The DM stated she had made the MS and the ADM aware of the stolen grease traps a year ago, but nothing had been done about it. The DM also stated she did not follow up with the MS or ADM because she thought they would take care of it. The DM stated she was unaware of any other means of grease…

    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 · Past Non-Compliance

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$8,190 in federal fines across 1 penalty.

  • $8,190 — penalty dated 2023-09-18

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to NEXION HEALTH — 51 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.2+0.8 vs chain
Health inspection 2 of 52.3-0.3 vs chain
Staffing 4 of 52.8+1.2 vs chain
Quality measures 5 of 52.6+2.4 vs chain
The other 50 homes this chain runs (chain average 2.2★, per CMS)
1 of 5Bay Ridge Healthcare CenterLa Porte, TX 1 of 5Claiborne Healthcare CenterShreveport, LA 1 of 5Cornerstone Rehabilitation And Healthcare CenterCorinth, MS 1 of 5Crystal Rehabilitation And Healthcare CenterGreenwood, MS 1 of 5Duncanville Healthcare and Rehabilitation CenterDuncanville, TX 1 of 5Flatonia Healthcare CenterFlatonia, TX 1 of 5Gonzales Healthcare CenterGonzales, LA 1 of 5Green Valley Healthcare and Rehabilitation CenterFort Worth, TX 1 of 5Grenada Rehabilitation And Healthcare CenterGrenada, MS 1 of 5Holly Springs Rehabilitation And Healthcare CenterHolly Springs, MS 1 of 5Indianola Rehabilitation And Healthcare CenterIndianola, MS 1 of 5Lily Springs Rehabilitation and Healthcare CenterLampasas, TX 1 of 5Meadowview Health & Rehab CenterMinden, LA 1 of 5New Iberia Manor SouthNew Iberia, LA 1 of 5Patterson Healthcare CenterPatterson, LA 1 of 5Picayune Rehabilitation And Healthcare CenterPicayune, MS 1 of 5Pierremont Healthcare CenterShreveport, LA 1 of 5Prairie Meadows Rehabilitation and Healthcare CentFloresville, TX 1 of 5The Bluffs Rehabilitation And Healthcare CenterVicksburg, MS 1 of 5Village Creek Rehabilitation and Nursing CenterLumberton, TX 1 of 5Willow Park Rehabilitation Health Care CenterClifton, TX 1 of 5Woodlands Rehabilitation And Healthcare CenterClinton, MS 1 of 5Yazoo City Rehabilitation And Healthcare CenterYazoo City, MS 2 of 5Great Oaks Rehabilitation And Healthcare CenterByhalia, MS 2 of 5Kaplan Healthcare CenterKaplan, LA 2 of 5Many Healthcare and Rehabilitation CenterMany, LA 2 of 5New Iberia Manor NorthNew Iberia, LA 2 of 5North Star Ranch Rehabilitation and Healthcare CenBonham, TX 2 of 5Willow Park Rehabilitation And Care CenterWillow Park, TX 3 of 5Barton Valley Rehabilitation and Healthcare CenterAustin, TX 3 of 5Cedar Ridge Rehabilitation and Healthcare CenterPilot Point, TX 3 of 5Columbia Rehabilitation And Healthcare CenterColumbia, MS 3 of 5Cross Timbers Rehabilitation and Healthcare CenterFlower Mound, TX 3 of 5Delta Rehabilitation And Healthcare CenterCleveland, MS 3 of 5Golden Creek Healthcare And Rehabilitation CenterNavasota, TX 3 of 5Lakeview Rehabilitation and Healthcare CenterWinnsboro, TX 3 of 5Midwestern Healthcare CenterWichita Falls, TX 3 of 5Natchez Rehabilitation And Healthcare CenterNatchez, MS 3 of 5Ridgecrest Healthcare And Rehabilitation CenterForney, TX 4 of 5Arbor Hills Rehabilitation And Healthcare CenterEagle Lake, TX

Showing 40 of 50; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleSince
BREEDEN, VICTORIAIndividualW-2 MANAGING EMPLOYEEsince 04/01/2022
MAK, DAVIDIndividualCORPORATE OFFICERsince 04/01/2022
NEXION HEALTH AT KINGSVILLE INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2022
FALLON, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2022
HERDRICH, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2022
KIRLEY, FRANCISIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2022
LEE, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2022
REID, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2022
RINER, MEERAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2022

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.

$6.9M
Net patient revenuemost recent cost report
+1.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 73%Medicare 3%Other / private 24%

About 73% 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.

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

$263per resident / day
operating cost
$7,998per month
≈ monthly operating cost
$266per 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 675494. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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