The Heights of League City

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.

32.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 39.4% 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 33 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 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% 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 123.4 residents a day — about 64% occupied, or roughly 71 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.38 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.29 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 3.08 hrs/resident/day on weekends vs 3.51 on weekdays — 12% thinner on weekends. RN hours go from 0.30 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 70% is well above 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.

28 citations, most serious first. The 19 most serious are shown; the remaining 9 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-03-19 · 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 interview and record review, the facility failed to consult with the resident's physician when there was 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 (CR #1) of 4 residents reviewed for notification of changes. 1. On [DATE], LVN B and LVN C failed to notify the physician when CR#1 had a significant change in condition where he refused all meals, had increased drowsiness, and had hypotensive BP readings of 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m. 2. On [DATE], CR#1 was sent to the hospital due to unresponsiveness and was placed in ICU. He required several rounds of CPR and was diagnosed with a blood infection, septic shock, and suffered an acute stroke.On [DATE] at 1:47 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2026-03-19 · 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 observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (CR#1) of 4 residents reviewed for quality care. 1. MA B and CNA B failed to notify LVN B and LVN C on [DATE] when CR#1 refused all meals, had increased drowsiness, and had hypotensive BP readings of 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m. In result, LVN's failed to seek medical guidance from CR #1's physician related to the change in condition until 8:30 am on [DATE] when he became unresponsive and was sent out via EMT.2. CR#1 required several rounds of CPR and was diagnosed with a blood infection, septic shock, and suffered an acute stroke.On [DATE] at 1:47 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-07-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 out of 1 resident (CR #1) reviewed for adequate supervision. The facility failed to provide adequate supervision to residents and adequate training of the staff regarding monitoring and documenting resident whereabouts (location) to mitigate accidents such as elopement when CR#1 eloped on 01/02/2025 and was found to have laceration to nose that required 3 sutures, a closed fracture to left wrist with splint in place, and a closed fracture to nasal bone. This noncompliance was identified as Past Non-Compliant Immediate Jeopardy (PNC IJ) was identified on 07/09/2025. The noncompliance began on 01/02/2025 and ended 01/31/2025. The facility corrected the noncompliance before the investigation began. The IJ began on 07/09/2025 and ended on 07/09/2025. The facility…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2025-03-07 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  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 personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 of 77 residents (CR #1) reviewed for CPR. LVN A failed to call out a change in condition and obtain assistance from available staff when CR #1 was found unresponsive. This led to a delay of approximately 3 minutes before CPR was started on CR #1 on [DATE]. LVN B failed to enter CR #1's DNR code status at the time of admission which resulted in LVN A making multiple phone calls to determine code status prior to initiating CPR. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:16 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the severity level of potential harm that was not immediate jeopardy because all staff had not been trained on [DATE]. These failures placed residents…

  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 before2025-01-13 · tag F0580 — failed to tell family and doctor about changes — pattern
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review the facility failed to immediately consult with the resident's physician when there is a significant change in the resident's physical status for 1 of 4 residents (CR #1) reviewed for notification of changes. The facility failed to ensure CR #1's physician was consulted when he was short of breath while receiving oxygen treatment. This failure could place residents at risk of respiratory distress or significant decline in physical or mental functioning. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:11 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of pattern because all staff had not been trained on notification of changes to the physician. The findings included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old male was admitted 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-01-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 1 of 4 residents (CR #1) reviewed for respiratory therapy. The facility failed to ensure CR #1 was provided with repiratory services to meet his needs. CR #1 ambulated with a walker approximately 30 feet without oxygen, slid out of a shower chair onto the floor and became unresponsive and later died. The facility failed to ensure CR #1 who was admitted with a verbal order for oxygen administration was documented, verified, and communicated to staff for proper implementation. This failure could place residents at risk of respiratory distress or dependency. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:11 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of no actual 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 · Jcited before2025-01-13 · 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, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (CR #1) of four residents reviewed for accidents, hazards, and supervision. -The facility failed to ensure CNA C followed CR#1's care plan when transferring CR#1 who required two staff for transfers. CR#1 slide out of shower chair onto the floor and became unresponsive and later died. -The facility failed to ensure CNA C followed CR#1's care plan when during ambulation. CR#1 ambulated with a walker instead of wheelchair as care planned. CR#1 slide out of shower chair onto the floor and became unresponsive and later died. These failures can place residents at risk of injury due to not being supervised properly. An IJ was identified on [DATE]. The IJ template was provided to the facility Administrator on [DATE] at 7:11 p.m. While the facility Administrator was informed that the IJ was removed on [DATE] at 2:58 PM, the facility remained…

  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 before2024-05-30 · 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 interview and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one resident (CR #1) of five residents (CR #1) reviewed for pharmacy services. 1. The facility failed to ensure CR #1's discharge orders from a transferring hospital were transcribed to the facility orders. 2. The facility failed to ensure CR #1's two anti-rejection medications were obtained by the facility. 3. The facility failed to ensure CR #1 received daily anti-rejection medications as ordered by the hospital from [DATE] to 05/23/24, when she was re-hospitalized and admitted to the ICU. 4. The facility failed to ensure CR #1, who had a liver transplant, was provided with two anti-rejection medications. An Immediate Jeopardy (IJ) situation was identified on 05/29/24. While the IJ was removed on 05/30/24 at 5:13 p.m., the facility remained 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-09-05 · 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 environment remained free of accident hazards and each resident received adequate supervision and assistance to prevent accidents for 1 of 6 residents (Resident#1) reviewed for accidents and hazards. The facility failed to ensure hot coffee was maintained at a temperature that prevented Resident #1 from sustaining a second-degree burn to his left groin. This failure could place residents at risk of second degree burns and a decline in quality of life. Findings Included Resident #1 Record review of Resident #1's admission face sheet, dated 8/25/2023, revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. His diagnoses included right eye cataract (blurry vision), dysphagia (difficulty swallowing), retinal hemorrhage left eye (bleeding from the blood vessel in the retina), sepsis (infection), dementia (memory loss), anxiety disorder (feeling of fear, dread and uneasiness), abnormalities…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-24 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferencesfor 1 of 4 residents (Resident #1) reviewed for pain management. The facility failed to administer prescribed pain medication and adequately address Resident #1's complaints of pain. As a result, Resident #1 experienced unrelieved pain, and left the facility AMA on 3/28/2026 due to the facility's inability to provide pain management as requested. This failure could place the residents at risk of a decrease in quality of life due to pain. Findings included: Record review of a face sheet dated 4/23/26 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included multiple sclerosis (a condition where the body's defense system mistakenly attacks the protective coating around the nerves in…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-19 · tag F0908 — failed to keep essential equipment working — isolated
  Keep all essential equipment working safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 4 (suction machine #1) suction machines reviewed for essential equipment. The facility failed to ensure the suction machine in CR #1's room was functioning correctly to suction oral secretions on 11/29/25, causing staff to get the suction machine from the crash cart.This failure could place residents at risk of not having their needs met due to a functional suction system not readily available.Findings included:Record review of CR #1's undated face sheet revealed she was an [AGE] year old female readmitted to the facility on [DATE] with diagnoses of Alzheimer's disease (brain disorder that destroys memory, thinking skills, and ability to carry out daily tasks), dysphagia (trouble swallowing), congestive heart failure (heart unable to pump effectively causing fluid in lungs), dementia significant decline in mental abilities), 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-13 · tag F0808 — failed to follow doctor-ordered diets — isolated
  Ensure 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a therapeutic diet was prescribed by the attending physician for one of 5 residents (CR #1) reviewed for food and nutrition services. The facility failed to ensure CR#1's diet order was transcribed and administered as ordered by the physician for a cardiac (2 GM sodium, low fat, low cholesterol) diet. This failure put residents at risk for health complications related to nonadherence to diet order. Findings included: Record review of CR#1's face sheet dated 12/07/24revealed a [AGE] year-old male was admitted to the facility on [DATE]. CR#1 had diagnoses included: heart failure, (heart cannot pulp enough blood and oxygen to the body's organ), morbid obesity (body mass index greater than 35 combined with other health issues) diabetes mellites (body does not manage blood sugar properly), and atrial fibrillation (irregular heartbeat). Record review of CR #1's admission MDS assessment dated [DATE] revealed CR #1 had BIMS score of 15 out of 15 which…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-08-21 · tag F0641 — pattern
  Ensure each resident receives an accurate 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 observations, interviews, and record review the facility failed to conduct initial and periodical and comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 4 (Residents #4, #7, #34, & #97) of 16 residents reviewed for accuracy of resident assessments. -Residents #4 was not assessed for her mental diagnoses condition on her admission MDS dated [DATE] MDS. -Resident # 4 was not accurately assessed for her hearing difficulty on her comprehensive MDS dated [DATE] and on her Quarterly MDS dated [DATE]. -Residents #7 was not assessed for her mental illness and her oral cavity on her annual comprehensive MDS assessment dated [DATE]. -Resident #34 was not assessed for her mental diagnoses. -Resident # 97 was not accurately assessed for he her oral cavity on her annual comprehensive assessment dated [DATE] These failures could place residents at risk of not receiving the care needed to maintain their highest, practicable, physical, social, and psychosocial level…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-08-21 · tag F0656 — failed to write and follow a full care plan — pattern
  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 ensure comprehensive resident centered care plans were reviewed and revised by the interdisciplinary team after each assessment for 7 residents reviewed for care plan accuracy (Residents #4, # 7, #10, #13, #48, #53, #70). -The facility failed to revise and update Resident #4's care plan to include her cognitive loss, dementia, mental illness of bipolar disorder, communication, and dental care that were triggered on her admission MDS assessment dated [DATE]. - Resident #7 care plan was not updated for cognitive function, visual Function, Psychosocial well-being and activities that were triggered on her annual MDS dated [DATE] -Resident #7's care plan was not updated to include her oral\dental care. --Resident #48's care plan was not updated to reflect DNR status. --Resident #13's care plan was not updated to reflect level of ADL care required. --Resident #48's care plan was not updated to reflect level of ADL care required. --Resident #53's…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-08-21 · 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

  Based on observation, interview, and record review the facility failed to ensure expired drugs were removed from the medication room used to store drugs and biologicals in accordance with currently accepted professional principles when applicable for 1 of 1 medication room, 4 of 7 medication carts observed for labeling and storage of drugs and biologicals. The facility failed to ensure expired medications stored in the medication storage room were removed and disposed according to facility procedures for drug destruction and drugs open were dated. This deficient practice could place residents who receive medications from the medication room at risk for receiving outdated medications and could result in residents not getting the intended therapeutic effects of their medications and worsening of residents' symptoms. Findings include: During observation on 08/20/24 at 1:30 PM, the following expired medications were found in the medication room with RN EE: 1. Meclizine Chewable 7 bottles 100 tablets expired 06/24 2. Prenatal for women before, during and after pregnancy 100 tablet…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-08-21 · tag F0640 — isolated
  Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to electronically transmit within 14 days after the facility completed a resident's assessment, encoded MDS data including a subset of items upon a resident's transfer, reentry, discharge, and death for 3 of 3 residents (CR #16, 44, and #114) reviewed for electronic transmission of MDS data to the CMS system. The facility failed to complete and transmit discharge MDS data to the CMS system for (CR #16, 44, and #114 residents within 14 days of Residents discharge from the facility. These failures could place residents at risk for not having their assessments transmitted timely and or having their long-term care nursing facility Medicaid payments and or services interrupted. Findings Include: CR #16 Record review of CR #16's Face Sheet dated 08/21/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of restlessness and agitation, respiratory failure, chronic kidney disease (long standing disease 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent a decline in range of motion for 1 (Resident #10) of 17 residents. The facility failed to ensure Resident #10 had interventions in place for her left side foot drop (difficulty lifting the front part of the foot) using the brace/splint to foot can help hold the foot in a normal position. This deficient practice placed residents at risk for decrease in mobility, range of motion, and could contribute to worsening of foot drop. Findings Include: Record review of Resident #10's annual MDS assessment, dated 07/06/24, reflected a [AGE] year-old female with an admission date of 10/16/18 and was re-admitted [DATE]. Her diagnoses included acute cystitis without hematuria (sudden inflammation of the bladder caused by a bacterial infection, also known as a urinary tract infection), cerebrovascular disease ( stroke, brain aneurysms and cerebral…

  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 · D2024-08-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #10) of two residents reviewed for incontinence care. -The facility failed to ensure CNA BB provided appropriate perineal care for Resident #10 after an incontinent episode when she failed to open and clean the labia. -The facility failed to ensure CNA BB cleaned and wiped around the resident's buttocks after an incontinent episode . These failures could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings include: Record review of Resident #10's annual MDS assessment, dated 07/06/24, reflected a [AGE] year-old female with an admission date of 10/16/18 and was re-admitted [DATE]. Her diagnoses included acute cystitis without hematuria (sudden inflammation of the bladder caused by a…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-21 · 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 that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 14.28%, based on 4 errors out of 28 opportunities, which involved 1 of 4 residents (Resident #93), and 1 of 4 staff (Medication Aide DD) reviewed for medication errors. -Medication Aide DD failed to administer 4 medications Ferrous Sulfate Tab EC 325 MG (iron supplement used to treat or prevent low blood levels of iron), Cholecalciferol Tab 50 MCG (2000 Unit) (a fat-soluble vitamin that helps your body absorb calcium and phosphorus), Gabapentin Cap 100 MG (used to treat epilepsy. It's also taken for nerve pain, which can be caused by different conditions) and Carbamazepine Tab 200 MG (an anticonvulsant. It works by decreasing nerve impulses that cause seizures and nerve pain, such as trigeminal neuralgia and diabetic neuropathy) to Resident #93 according to physician orders. This failure could place residents at risk 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.

  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

$144,668 in federal fines across 6 penalties.

• $21,610 — penalty dated 2026-03-19
• $17,345 — penalty dated 2025-07-10
• $24,622 — penalty dated 2025-03-07
• $18,353 — penalty dated 2025-01-13
• $55,278 — penalty dated 2024-05-30
• $7,460 — penalty dated 2023-09-05

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 TOUCHSTONE COMMUNITIES — 25 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 36 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.

14 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 $594K 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