Monument Rehabilitation and Nursing Center
120 State Loop 92, La Grange, TX 78945 · Government - Hospital district · 104 certified beds · (979) 968-3144 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2024
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,281 in federal fines (most recent 2025-07-02)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 held steady at 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.1% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.3% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 2.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 6.2% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.5% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.5% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.8% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 12.8% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.9% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 90.0% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.3% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.7% | 12.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 4.19 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.38 | 2.06 | 1.80 | worse |
* 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.
37.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 70.3% 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 37 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 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 37.5%CMS range 26.1–50.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.0%CMS range 7.8–19.0 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 70.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 59.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 70.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 85.1% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | not 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 stay | 4.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.0%CMS range 3.9–15.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.14 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 104 beds and averages 61.1 residents a day — about 59% occupied, or roughly 43 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.57 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.35 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 2.28 hrs/resident/day on weekends vs 2.68 on weekdays — 15% thinner on weekends. RN hours go from 0.62 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 54% 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
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.
21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.
- Immediate jeopardy · J2025-07-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, interviews, and record reviews, the facility failed to provide adequate supervision for 1 of 5 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident #1 received adequate supervision to prevent elopement. On 04/08/2025, Resident #1 eloped from the facility through a side door and was later found by a neighbor in a grassy area approximately 219 feet away from the facility. This failure placed the resident at risk for serious harm.The non-compliance was identified as past non-compliance. The immediate jeopardy began on 04/08/2025 and ended on 04/14/2025. The facility had corrected the noncompliance prior to the start of the survey. The facility had implemented corrective actions and returned to compliance before the investigation began.This failure had the potential to affect other residents and could result in residents not receiving appropriate supervision, placing them at risk for serious injury, harm, or death. Upon entry to the facility,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-01-28 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
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 residents remained free of any significant errors for 1 of 3 residents (Resident # 1) reviewed for medication error. The facility failed to ensure Resident #1 received the correct dosage of Primidone required for treating tremors. Resident #1 was given Primidone 50 mg oral tablet 1 tablet by mouth 2 times a day from 12/11/2025 until 01/07/2026. The order from the hospital discharge was written as Primidone 50 mg oral tablet 2 tablet by mouth 2 times a day. The failure could place residents at risk of complications such as increased tremors. The findings included: Review of Resident #1 face sheet, dated 01/28/2026, revealed he was initially admitted to the facility 12/11/2025 with diagnosis including, type 2 diabetes (body does not produce enough insulin), kidney disease (kidneys are not filtering correctly), urinary tract infection (bladder infection) and Essential tremor (shaking you can't control) Review of Resident #1's quarterly MDS assessment, dated 12/02/2025 revealed his BIMS score was 08 out 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.
- Potential for harm · E2025-09-11 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 3 of 5 residents reviewed for immunizations. (Residents #14, #28 and #5) A) The facility failed to document in Resident #14's medical records for having had received education, whether by self or with responsible party, of the benefits, and potential side effects, of the pneumococcal immunization or having had not received the pneumococcal immunization due to medical contraindication or refusal. B) The facility failed to document in Resident #28's medical records for having had received education, whether by self or with responsible party, of the benefits,…
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.
- Potential for harm · E2025-09-11 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 3 of 5 residents who were reviewed for immunizations. (Residents #14, #28 and #5) The facility failed to document in Resident #14, #28 and #5's medical records for having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. Findings include: Review of Resident #14's face sheet…
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.
- Potential for harm · D2025-09-11 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS system for 1 of 3 discharged residents (Resident #29) reviewed for closed records. The facility failed to complete and transmit a discharge MDS assessment for Resident #29, who discharged on [DATE], within 14 days of the discharge date . This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required. The findings included: Record review of Resident # 29's admission face sheet undated reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, hypertension (high blood pressure), hyperlipidemia (fat particles in the blood), major depressive disorder, adjustment disorder, dehydration, insomnia, shortness of breath, hypokalemia, anxiety disorder, edema, muscle wasting and atrophy, dysphagia, acute upper respiratory infection, edema, dyspnea, and cognitive communication deficit. Record review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-11 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents reviewed for during medication passMA B failed to wash her hands prior or during medication administration to Resident #21and Resident #43.These failures could place residents at risk for developing wounds, upper respiratory infections and risk for healthcare associated cross-contamination and infections. Findings include: Review of Resident #21's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: coronary heart disease (term for the buildup of plaque in the heart's arteries that could lead to heart attack or ischemic stroke), hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest…
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.
- Potential for harm · E2024-07-31 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of eight residents (Resident # 8, Resident #18, Resident #34, and Resident #50). 1. The facility failed to ensure Resident #18 and Resident #50's facial hair was removed. 2. The facility failed to ensure Resident # 8, and Resident # 34's nails were cleaned and did not have any rough edges. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Record review of Resident # 18's Face Sheet dated, 07/31/2024, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of muscle wasting and atrophy, not elsewhere classified, multiple sites ( thinning or loss of muscle tissue), lack of coordination (uncoordinated movement due to a muscle control problem that causes inability to coordinate movements),…
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.
- Potential for harm · E2024-07-31 · tag F0808 — failed to follow doctor-ordered diets — patternEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 provide the physician prescribed therapeutic diet to 11 of 13 residents (Resident # 3, Resident # 9, Resident # 10, Resident # 12, Resident # 13, Resident # 22, Resident # 23, Resident # 25, Resident # 36, Resident # 156, and Resident # 207) reviewed for therapeutic diets, in that: Resident # 3, Resident # 9, Resident # 10, Resident # 12, Resident # 13, Resident # 22, Resident # 23, Resident # 25, Resident # 36, Resident # 156, and Resident # 207did not receive a mechanical soft diet as ordered. This failure could place residents at risk for choking and causing further health issues. Findings included: A record review of Resident # 3's diet order dated 8/29/22 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # 9's diet order dated 8/29/22 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # !0's diet order dated 7/10/24 reflected an order for Regular diet mechanical sift…
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.
- Potential for harm · E2024-07-31 · tag F0810 — patternProvide special eating equipment and utensils for residents who need them and appropriate assistance.
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 special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive device when consuming meals and snacks for 1 resident (Resident # 2) of 8 residents reviewed for assistive devices. The facility failed to provide Residents# 2's physician ordered handled cup with lid for lunch. This failure put resident at risk for decreased fluid intake, dehydration, and decreased quality of life. Findings included: A record review of Residents # 2's face sheet dated 7/31/24 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral palsy (A congenital disorder of movement, muscle tone, or posture.), intellectual disabilities (A neurodevelopmental condition that affects a person's intellectual functioning and adaptive behavior.), muscle wasting and atrophy (The loss of muscle mass and strength), dysphagia (Difficulty swallowing foods or liquids,…
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.
- Potential for harm · E2024-07-31 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 one of one kitchen reviewed for sanitation. 1. The facility failed to ensure all items were labeled and dated. 2. The facility failed to ensure all items were covered and stored properly. 3. The facility failed to ensure sanitation practices were occurring in kitchen. 4. The facility failed to ensure temperature logs were being completed. These failures placed residents at risk of foodborne illness. Findings included: Observation of the kitchen's ice machine on 7/29/24 at 7:00 am revealed the inside of the machine to have black debris and growth growing on the upper inside of the machine near the door. Observation of ice scoop receptacle on wall next to ice machine on 7/29/24 at 7:05 am revealed inside of receptacle to have dried brown appearing substance at the bottom of the receptacle. Observation of kitchen prep area worktable on 7/29/24 at 7:08 am revealed a staff member had a Styrofoam cup 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.
- Potential for harm · Ecited before2024-07-31 · tag F0880 — failed to prevent and control infections — patternProvide 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 observations, interviews, and record review, the facility failed to maintain an infection control 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 4 of 8 (Resident #2, Resident #11, Resident #19 and Resident #44) residents reviewed for infection control practices. 1. Business Office Manager failed to don PPE according to the facility protocol prior to entering COVID isolation. 2. The CNAs serving food trays failed to ensure Resident #44 was served his meal under safe sanitary conditions. 3. Activity Director observed assisting Resident # 11 in dining room with meal set up touching ready to eat food items with ungloved hands and without performing hand hygiene in between residents. 4. CNA A observed passing hall tray for Resident # 2 and assisting Resident # 2 with meal tray set up with ungloved hands and without performing hand hygiene between residents. These…
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.
Show the remaining 10 citations
- Potential for harm · D2024-07-31 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to be treated with respect and dignity for one (Resident # 11) of eight residents reviewed for dignity. Resident # 11 waited 14 minutes staring at her meal tray before a staff member set down to assist with feeding Resident # 11. This failure placed residents at risk of not being treated with dignity. Findings included: A record review of Residents # 11's face sheet dated 7/31/24 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), traumatic subarachnoid hemorrhage (bleeding on the brain), wedge compression fracture of the T5-T6 vertebra (spinal fracture), major depressive disorder ( A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life.), cervicalgia (Neck pain),and anxiety disorder (A mental health disorder characterized by feelings…
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.
- Potential for harm · D2024-07-31 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 2 (Resident # 9 and Resident #47) out of 8 residents reviewed for call lights. The facility failed to ensure Resident #9 and Resident #47's call light was within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #9's Face Sheet, dated 07/31/2024, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of history of falling (balance issues or other health conditions that increase the risk of falling), unspecified lack of coordination (uncoordinated movement due to a muscle control problem that causes inability to coordinate movements), and abnormal posture ( rigid body movements and chronic abnormal positions of the body.). Record review of Resident #9's Annual…
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.
- Potential for harm · D2024-07-31 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to provide a safe, clean, comfortable, and homelike environment; including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for one (Resident #1) of 8 residents reviewed for homelike environment. The facility failed to ensure two bedside tables were cleaned daily for three days observed during annual survey. This failure placed residents at risk for infections, injuries, and demoralization. The findings included: Review of the Face Sheet for Resident #1 reflected she was admitted on [DATE] with diagnosis of: hemiplegia to left side ( paralysis of limbs on the left side of body), metabolic encephalopathy (problem of the brain, history of traumatic brain injury (disruption in the normal function of the brain, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), epilepsy, unspecified convulsions ( a group of disorders marked by problems in the normal functioning of the brain), and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0801 — isolatedEmploy 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 observation, interview, and record review, the facility failed to have sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for one cook (Cook G) of three dietary cooks reviewed for qualified dietary staff in that: Cook G had not received onboarding training with the appropriate competencies and skills to carry out the functions of the food and nutrition services department. This failure could place residents at risk of not having their nutritional needs met and place them at risk of food borne illness. Findings included: During an interview on 7/29/24 at 9:00 am the DD said all her staff including herself had the Texas Food Handlers License except for [NAME] G who was new and just started in the early part of July 2024. The DD said [NAME] G will be coming in to take her Texas Food Handlers course this week and get their food handlers license . The DD said [NAME] G had recently transitioned from the housekeeping department to dietary department. The DD said [NAME] G has worked several shifts since…
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.
- Potential for harm · D2024-07-31 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 review the facility failed to ensure the residents were free from abuse, neglect, misappropriation of resident property, and exploitation for one (1) of five (5) residents reviewed for abuse. The facility failed to protect Resident #1 from abuse when staff yelled at her when asking for assistance via call light. The noncompliance was identified as Past Noncompliance 07/30/24. The noncompliance began on 07/22/24 and ended on 07/29/24. The facility had corrected the noncompliance before the survey began. These failures placed residents at risk of experiencing and enduring abuse by facility staff causing decreased quality of life. Findings Included: Review of the Face Sheet for Resident #1 reflected she was admitted on [DATE] with diagnosis of: Hemiplegia to left side, Metabolic encephalopathy, Hx of Traumatic Brain Injury, Muscle wasting and atrophy, epilepsy, Unspecified convulsions, need for personal care. Review of the quarterly MDS assessment for Resident #1 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.
- Potential for harm · D2023-06-08 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents has the right to be informed of, and participate in, their treatment for one (Resident #17) of four residents reviewed for resident rights. -The facility failed to ensure Resident #17'ss wishes to discontinue use of Estradiol (estrogen). This failure could place residents at risk of not being part of the decision-making process for their care. The findings included: Record review of Resident #17's admission record revealed a [AGE] year-old resident admitted on [DATE]. Resident #17 diagnoses included cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood), unspecified dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (decrease in size or wasting away of a body part or tissue arrested development),…
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.
- Potential for harm · D2023-06-08 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 6 residents (Resident#17) reviewed for unnecessary drugs. The facility failed to ensure Estradiol (a female hormone that regulates many functions in the body, such as reproduction, mood, and bone health) was appropriate for Resident #17. Estradiol was prescribed for one documented incident of sexualized behavior which is an off-label use. This failure could place residents receiving medications at risk of a possible inappropriate drug use or adverse drug reaction. hospitalization. Findings included: Record review of Resident #17's admission record revealed a [AGE] year-old resident admitted on [DATE]. Resident #17 diagnoses included cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood), unspecified dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere 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.
- Potential for harm · D2023-06-08 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, interviews and record review the facility failed to ensure all drugs and biologicals were stored securely for three (Nurse Cart 2B Hall, Med Aide Cart 1A Hall, Nurse cart 2A Hall) of four medication carts reviewed for storage of medications. Nurse Cart 2B Hall, Med Aide Cart 1A Hall and Nurse cart 2A Hall had punctured protective seals on the back of multiple narcotic medication blister pill cards. This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion. Findings included: Nurse Cart 2B Hall: Observation on 05/31/2023 at 10:00am revealed the narcotic storage of Lorazepam 0.5mg tablets #5 and #6 of 9 tablets had torn protective seals. A second blister card of Lorazepam 0.5mg, tablet #3 of 4 tablets had a torn protective seal. A third blister card of Lorazepam, tablet #6 of 30 tablets had a torn protective seal. In an interview on 05/31/2023 at 10:00AM, LVN E stated if the resident needed a dose of Lorazepam, he would use the tablets with the broken seal first. LVN…
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.
- Potential for harm · Dcited before2023-06-08 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 one of 8 residents reviewed for infection control (Resident #30). The facility failed to ensure the needle used on Resident #30, remained sterile during the procedure for intramuscular injection of the antibiotic Ceftriaxone. This failure could place residents at risk of infection, decline in health and hospitalization. Findings included: Record review of Resident #30's face sheet revealed a [AGE] year-old male admitted to the facility 02/21/2021 and initially admitted on [DATE]. His diagnoses included atrial fibrillation (abnormal heart rhythm), Parkinson's disease, muscle wasting, pain in joints, age related debility, behavioral and emotional disorder, depression, non-cancerous tumor of the salivary gland, HTN and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-07-31 · tag F0577 — patternAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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 place the most recent survey readily accessible to residents in a place most frequented by residents for 9 of 9 residents reviewed for resident group meeting. The facility failed to have the survey manual readily accessible for residents to view the surveys. This failure could place residents at risk of not being able to fully exercise their rights to be informed of the facility's survey citation history. Findings included: Observation on 07/29/2024 at 3:00 PM revealed that the facility did not locate the survey book in common areas of the facility. There was no sign seen that reflected where the survey book was located. Observation on 07/30/2024 at 9:30 AM revealed that the state surveyor was unable to locate the survey book in common areas of the facility. There was no sign seen that reflected where the survey book was located. Record review of the Resident Council Minutes on 07/30/2024 from 8:30 AM to 8:50 AM revealed that during the Resident Council Meetings from 04/2024 to 07/2024 the residents were not…
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.
“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.
- 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.
Fines & penalties
$8,281 in federal fines across 1 penalty.
- $8,281 — penalty dated 2025-07-02
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 WELLSENTIAL HEALTH — 67 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.7 | +1.3 vs chain |
| Health inspection | 4 of 5 | 2.9 | +1.1 vs chain |
| Staffing | 2 of 5 | 1.6 | +0.4 vs chain |
| Quality measures | 4 of 5 | 4.2 | -0.2 vs chain |
The other 66 homes this chain runs (chain average 2.7★, per CMS)
Showing 40 of 66; 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 / manager | Type | Role | Since |
|---|---|---|---|
| REGENCY IHS OF LA GRANGE LLC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2025 |
| LUCAS, DENISE | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| SIPTAK, TRINA | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| VASQUEZ, RAYMUNDO | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2020 |
| CSV RHEA MANAGEMENT HOLDCO, LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2025 |
| DWD TX HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2025 |
| JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2025 |
| REG BRIDGE OPCO LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2025 |
| REG HG OPCO LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2025 |
| REG OPERATOR HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2025 |
| REGENCY INTEGRATED HEALTH SERVICES LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2025 |
| REGENCY TEXAS HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2025 |
| BAIRD, DANIEL | Individual | INDIRECT OWNERSHIP INTEREST | since 04/13/2021 |
| CLAPP, BARBARA | Individual | INDIRECT OWNERSHIP INTEREST | since 06/01/2021 |
| CORTESE, DAREN | Individual | INDIRECT OWNERSHIP INTEREST | since 08/10/2021 |
| DEKOWSKI, DONOVAN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2018 |
| GIBSON, PATRICIA | Individual | INDIRECT OWNERSHIP INTEREST | since 08/01/2021 |
| MANDELBAUM, ELLIOT | Individual | INDIRECT OWNERSHIP INTEREST | since 10/01/2018 |
| MURRELL, EDWARD | Individual | CORPORATE OFFICER | since 11/22/2016 |
| ROLLO, JEFFERY | Individual | CORPORATE OFFICER | since 02/01/2021 |
| STRAMECKI, ANTHONY | Individual | CORPORATE OFFICER | since 11/01/2016 |
| VRATIS, KACEY | Individual | CORPORATE OFFICER | since 01/01/2020 |
| WAY, GEORGE | Individual | CORPORATE OFFICER | since 02/01/2018 |
| 120 STATE LOOP 92 LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2018 |
| REGENCY IHS CLINICAL CONSULTING, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2025 |
| REGENCY IHS REHAB LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2025 |
| WINNIE-STOWELL HOSPITAL DISTRICT | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2025 |
| CHUDLEIGH, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
CMS files one row per role, so the 59 rows in the source record cover these 28 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.
13 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.
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
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.
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 455715. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-11, 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.