Kingwood Rehabilitation and Healthcare Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

44.1% 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 69 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 28.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 25 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 194 beds and averages 78.8 residents a day — about 41% occupied, or roughly 115 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 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 2.90 hrs/resident/day on weekends vs 3.60 on weekdays — 19% thinner on weekends. RN hours go from 0.36 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 73% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

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

29 citations, most serious first. The 17 most serious are shown; the remaining 12 are one tap away and print in full.

• Immediate jeopardy · J2025-06-29 · 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 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 and furnish services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 11 residents (CR #1and Resident #34) reviewed for comprehensive care plans.The facility failed to care plan CR #1 for risk of elopement and document interventions prior to CR #1 eloping from the facility on 06/20/2025 around 4:45pm and did not know her whereabouts until 06/20/2025 around 8:40pm.The facility failed to assess and follow-up on Resident #34 in a timely manner when resident experienced excessive coughing/choking episode while eating breakfast on 06/24/25 at 8:48AM.This was determined to be an IJ on 6/26/25. The Administrator and DON were notified on 6/26/25 at…

  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 · Jcited before2025-06-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations , interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 out of 11 residents (CR#1 and Resident # 58) reviewed for adequate supervision and accident hazards. -CR #1 left the faciity on [DATE] around 5:45pm and the facility was not aware of CR #1's whereabouts until 06/20/2025 at 8:42pm when they received notice CR #1 was found walking on the road near the facility . This was determined to be an IJ on 6/26/25 for CR #1's elopement. The Administrator and DON were notified on 6/26/25 at 4:23pm. The DON and Administrator were provided with the IJ template on 6/26/25 at 4:27pm and a Plan of Removal was requested. The IJ was lowered on 06/29/2025 at 11:40am with the Administrator and DON, While the IJ was lowered, the facility remained out of compliance at a scope of isolation and a severity of harm with potential 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
• Immediate jeopardy · K2025-06-03 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  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 observations, interviews and record reviews the facility failed to ensure 4 (CR#2, CR#3 R#1 and R#2) of 9 resident reviewed was free from abuse and neglect The facility failed to prevent neglect and failed to provide the required structures and processes in order to meet the needs of CR#2 when interventions were not implemented: WCD orders for changing bandages, turning, and repositioning, and getting CR#2 in the chair twice daily. As a result, CR#2 did not receive proper treatment to prevent wound deterioration and infection, which resulted in hospitalization with severe sepsis and required surgical wound debridement. An Immediate Jeopardy (IJ) was identified on 5.28.2025. The IJ template was provided to the facility on 5.28.2025 at 1:15p.m. While the IJ was removed on 6.1.25 at 6:25p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-06-03 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interviews and record review the facility failed to implement the facility's abuse policy ensuring 1 (CR#3) of 9 residents was free from abuse reviewed for developing/implementing abuse policies. The facility failed to implement their abuse policy when CR #3 made an allegation of physical and verbal abuse. The allegation was not reported to the abuse coordinator or investigated and the alleged abuser had access to CR#3 after an allegation of abuse was made. An Immediate Jeopardy (IJ) was identified on 5.30.2025. The IJ template was provided to the Administrator and DON on 5.30.2025 at 1:27p.m. While the IJ was removed on 6.1.25 at 6:25 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for physical harm and mental anguish. Findings included: Record Review…

  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
• Immediate jeopardy · K2025-06-03 · tag F0610 — failed to investigate and act on abuse reports — pattern
  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 interviews and record review the facility failed to immediately investigation, report and protect 1 (CR#3) of 9 residents reviewed for abuse and neglect. The facility failed to immediately investigate, report, and protect CR#3 when he reported being stabbed in the arm with an insulin needle and scratched on the nose by LVN B. They facility failed to prevent further potential abuse when the facility failed to remove CR#3 from LVN B care after the report of abuse. An Immediate Jeopardy (IJ) was identified on 5.30.2025. The IJ template was provided to the Administrator and DON on 5.30.2025 at 1:27p.m. While the IJ was removed on 6.1.25 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for physical harm and mental anguish. Findings included: Record Review of…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-06-03 · 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 interviews and record review the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual ' s clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (CR2, R#1, R#2) of 9 residents reviewed for Treatment/Services to Prevent/Heal Pressure Ulcers in that: The facility failed to ensure CR #2's wound interventions were implemented: WCD orders for changing bandages, turning, and repositioning, and getting CR#2 in the chair twice daily. As a result, CR#2 did not receive proper treatment to prevent deterioration and infection, which resulted in hospitalization with severe sepsis and surgical wound debridement. Facility failed to provide wound care daily as…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-06-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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, interviews and record review the facility failed to ensure resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 9 residents (CR #1) reviewed for accidents and supervision, in that: The facility failed to ensure CR#1 was transferred properly per therapy assessments and instruction, by CNA B. CR#1, a bedbound resident, who was totally dependent on staff for care sustained an unexplained head injury and hip fracture in her room alone. The facility failed to ensure precautionary interventions in place for CR#1, who was a known fall risk. An Immediate Jeopardy (IJ) was identified on 5.22.2025. The IJ template was provided to the Administrator on 5.22.2025 at 1:07 p.m. While the IJ was removed on 5.25.25 at 3:38 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-29 · tag F0685 — pattern
  Assist a resident in gaining access to vision and hearing 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 ensure that 1 (Resident #61) of 5 residents reviewed for hearing services, received proper treatment to maintain hearing capabilities. -The facility did not complete an Audiology (hearing) referral for Resident #61 who was hard of hearing until 06/27/25. -The facility failed to identify that Resident #61's hearing aids were not functioning properly when resident placed new batteries in hearing aids. This failure could place residents at risk for further decrease in communication, social engagement, and decrease in quality of life.Findings included: Record review of Resident #61's face sheet dated 06/26/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and again on 04/02/24. Resident's diagnoses included dementia (brain disorder that causes problems with thinking, memory, and behavior), type 2 diabetes mellitus (body has trouble controlling blood sugar and using for energy), heart failure, heart disease, depression,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-29 · 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 properly store, label, and/or secure medications and biologicals for 1 of 4 medication carts (400 hall medication cart), in accordance with State and Federal laws, all drugs and were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to for 1 of 14 residents reviewed for medication administration (Resident #67).The facility failed to ensure Resident #67 medication was not left unattended on [DATE], 600-hall medication cart had medication open not dated.This failure could place residents at risk to having access to unauthorized medication and/or lead to possible harm or drug diversion and receiving the appropriate medications and not reaching the intended therapeutic dose and possible exacerbation of health conditions.Findings included: Record review of Resident #67's face sheet, dated [DATE], revealed Resident #67 was admitted to the facility on [DATE] and re-admitted on…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-29 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 5 residents (Resident #34) reviewed for resident rights. -The facility failed in notifying Resident #34's physician on 06/24/25 right away when resident had a significant change in condition. Resident experienced a choking episode while eating his breakfast at 8:48AM on 06/24/25. This failure placed all residents in the facility who may experience a significant change in condition at risk for harm or injury if not reported to the physician in a timely manner. Record review of Resident #34's face sheet dated 06/26/25 revealed an [AGE] year-old man admitted to the facility on o2/24/22 and again on 04/03/23. Resident diagnoses included the following: Parkinson's Disease…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-29 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 3 errors out of 37 opportunities, resulting in a 8 percent medication error involving for 1 of 14 residents (Resident #67) reviewed for medication errors. LVN J did not administer the full dose of carvedilol oral tablet 3.125 mg (carvedilol=medication used to help lower blood pressure and reduce the workload of the heart).Misoprostol oral tablet 100 mcg (misoprostol= medication used to protect the stomach against acid damage, and decreases the amount of acid produced by the stomach) and Famotidine oral tablet 40 mg (famotidine) (medication used to reduce the amount of acid produced in your stomach) as ordered by the Physician to Resident #67 on 6/24/25. These failures could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.The findings included: Record review of Resident #67's face sheet, dated 6/24/25,…

  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 before2025-06-29 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection 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 (Residents #8 and #41) of 4 residents reviewed for infection control practices. -LVN A did not wipe his accu-check machine between after using it on Resident #8 and Resident #41 to check their blood glucose and did not store the accu-check machine properly to prevent infection on 06/24/2025. This failure could put residents at risk of a spread of infection and diseases due to not following infection control policies and procedures.Findings included: Record review of Resident #8's face sheet dated 06/25/2025, reflected she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included obesity, type 2 diabetes mellitus (high blood sugar), personal history of urinary…

  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 before2024-05-16 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 4 of 8 residents (Resident #68, Resident #18, Resident #25, and Resident #3) reviewed for pharmacy services. -LVN J and LVN C failed to ensure the narcotic count was correct during shift change for Resident #68, Resident #18, Resident #25, and Resident #3. - LVN J failed to document the administration of narcotic medications in a correct manner for Resident #68, Resident #18, Resident #25, and Resident #3. -Staff administered Tramadol 50 mg instead of Tramadol 37.5 mg - Acetaminophen 325 mg as ordered by the Physician to Resident #68 for an unknown period. These failures could place residents at risk for drug diversion and delay in medication administration. Findings include: Resident #68 Record review of Resident #68's face sheet dated…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-05-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review, the facility failed to ensure residents were provided with a reasonable accommodation to access the ability to call for staff assistance through a communication system for one of twenty-four (Resident #79) reviewed for call system placement. -Resident #79's call light cord was wrapped around the call light base on the wall in an area inaccessible to the resident. This failure could place this resident or other residents at risk for not having their call light answered timely in an emergency and staff not being aware of an emergency situation for an extended period of time, injury, or death. Findings include: Record review of Resident #79's face sheet revealed a [AGE] year-old man admitted on [DATE]. Record review of Resident #79's diagnoses detail report dated 5/15/2024 revealed his diagnoses included metabolic encephalopathy (brain disease, damage, or malfunction usually related to inflammation within the body), pulmonary embolism (condition in which one 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-05-16 · tag F0645 — isolated
  PASARR screening for Mental disorders or Intellectual Disabilities
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorders, intellectual disabilities, or a related conditions for level II resident review upon a significant change in status assessment for 1 of 18 residents (Resident #48) reviewed for PASARR evaluations. The facility failed to refer Resident #48 to the appropriate, State-designated authority when she was diagnosed with delusional disorder (firmly held false beliefs), mood disorder (psychiatric disorders that impact emotions), generalized anxiety disorder (over worry), psychosis (difficulty determining what is real or not), and bipolar disorder (mood disorder with ups and downs). This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a possible decline in mental health. Findings included: Record review of Resident #48's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE], with diagnoses of high blood…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-05-16 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  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 observations, interviews, and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #35) of 18 residents reviewed for quality of care. -LVN M failed to document notification to NP B of Resident #35's blood sugar of 422 on 5/13/24, and failed to document and/or give 10u of Insulin that was ordered by NP B for Resident #35's blood sugar. This failure could place the resident at risk for high blood sugar, and possible hospitalization. Findings include: Record review of Resident #35's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with an original admission date of 7/20/17. He had diagnoses of Type 2 Diabetes (body does not produce insulin or resists it), benign prostatic hypertrophy (enlarged prostate), cerebrovascular accident (stroke), anxiety, depression, hypertension (high blood pressure), insomnia…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-05-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
  Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure a psychotropic drug that affects brain activities associated with mental processes and behavior is free from unnecessary drugs for one of five residents (Resident #79) reviewed for unnecessary drugs. -The facility failed to document a correct diagnosis, monitor its effectiveness, and side effects of Seroquel (antipsychotic medication) prescribed for Resident #79. This failure affected one resident and placed him at risk of receiving unnecessary medications. Findings include: Record review of Resident #79's face sheet revealed a [AGE] year-old man admitted on [DATE]. Record review of Resident #79's diagnoses detail report dated 5/15/2024 revealed his diagnoses included: dementia (group of symptoms that affects memory, thinking, and interferes with daily life), affective disorder (a set of psychiatric disorders, also called mood disorders), and anxiety disorder (group of mental illnesses that cause constant fear and worry). Record review 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.

  Pharmacy Service 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

$72,573 in federal fines across 1 penalty.

• $72,573 — penalty dated 2025-06-03

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 MOMENTUM SKILLED SERVICES — 9 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 29 rows in the source record cover these 16 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.

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

This home reported $437K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in TX