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Magnolia Place Health Care

1620 Magnolia St., Liberty, TX 77575 · For profit - Partnership · 118 certified beds · (936) 336-8844 Medicare & Medicaid certified

Call the home — (936) 336-8844 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 23 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1400 N Travis St · (936) 334-1185 · Call to confirm hours
Pharmacy
1000 N Main St · (936) 641-9395 · Call to confirm hours
Grocery
1111 Main St · (281) 704-1744 · Call to confirm hours
Park
1021 Main St · Typically dawn to dusk
Place of worship
2005 Edgewood Ave

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 improved from 2 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.6%15.8%15.4%better
Long-stay residents who lose too much weight0.5%3.0%5.4%better
Long-stay residents with a catheter left in their bladder1.3%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.8%0.8%2.0%typical for the state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms2.6%2.4%6.5%typical for the state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.2%3.3%3.3%better
Long-stay residents whose ability to walk worsened15.6%14.0%16.1%typical
Long-stay residents on antianxiety or hypnotic medication9.3%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers2.2%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control9.5%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table13.8%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine70.0%88.0%79.4%worse
Short-stay residents rehospitalized after admission40.2%25.7%22.6%worse
Short-stay residents with an outpatient ER visit11.2%12.3%12.0%typical
Long-stay hospitalizations per 1,000 resident days3.032.171.67worse
Long-stay outpatient ER visits per 1,000 resident days2.872.061.80worse

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.

62.3% 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 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.3%U.S. median 51.5%
Got home and stayed home
11.8%U.S. median 10.7%
Went back to hospital
0.30U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 60% of this home’s weekday level — it runs therapy at close to weekday levels right through 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF62.3%CMS range 46.8–77.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.8%CMS range 8.1–17.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.1%CMS range 5.1–13.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.291.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.56
RN hours/ resident / day
0.68
LPN hours/ resident / day
2.48
Aide hours/ resident / day
3.73
Total nurse hours/ resident / day
0.47
RN hoursweekends
51.8%
Total nursing turnover
0.0%
RN turnover

How full it usually is: this home is certified for 118 beds and averages 65.1 residents a day — about 55% occupied, or roughly 53 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 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 is at or above 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 2.94 hrs/resident/day on weekends vs 4.05 on weekdays — 27% thinner on weekends — a notable drop. RN hours go from 0.60 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.

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

7
deficiencies at the latest standard inspection (2025-06-04)
13
at the previous standard inspection (2024-05-21)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · F2025-06-04 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    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 be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of all residents reviewed. 1. The Administrator failed to ensure he, the DON, and the IP received training on Enhanced Barrier Precautions. 2. The Administrator failed to implement Enhanced Barrier Precautions for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. This failure could cause residents not to receive appropriate care resulting in an increase in infections. Findings included: During observations on 06/02/25 during initial tour from 09:15 a.m. through 11:03 a.m. there were no resident rooms with any EBP signage on the doors or PPE set up outside or inside the resident rooms. During general observations on 06/02/25 from 11:30 a.m. through 04:00 p.m. there were no resident rooms with any EBP signage on the…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-06-04 · tag F0945 — failed to train staff on abuse prevention — widespread
    Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
    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 as part of its infection prevention and control program mandatory training included the written standards, policies, and procedures for the program for 11 of 12 employees, new and existing staff, (Administrator, DON, ADON/IP, LVN E, LVN H, CNA A, CNA B, CNA F, CNA I, CNA J, and CNA K) reviewed for training. 1. The facility failed to ensure the Administrator, DON, ADON/IP were trained on EBP (an infection control strategy that uses gloves and gowns during high- contact resident care to reduce spread of MDRO) (MDRO- bacteria that have become resistant to certain antibiotics) 2. The facility failed to ensure LVN E and LVN H were trained on EBP. 3. The facility failed to ensure CNA A, CNA B, CNA F, CNA I, CNA J and CNA K were trained on EBP. These failures could place residents at risk of illness due to lack of staff training. Findings include: Record review of a facility's in-service on 06/04/25, titled, Enhanced Barrier Precautions, indicated, It is the policy of this facility to implement enhance barrier…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-04 · tag F0552 — pattern
    Ensure 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 interview and record review, the facility failed to ensure residents had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 2 of 5 residents (Residents #6 and #64) reviewed for psychoactive medications. 1. The facility failed to ensure Resident #6 had a completed psychotropic consent from the resident or family for Seroquel (antipsychotic medication) before administering to Resident #6 on 09/09/24. 2. The facility failed to ensure Resident #64 had a completed psychotropic consent from the resident or family for Seroquel (antipsychotic medication) and Cymbalta (antidepressant) before administering to Resident #66 on 01/03/25. These failures could place residents at risk for receiving unnecessary antipsychotic medications without informed consent. Findings included: 1. Record review of Physician…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-04 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to 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 6 of 6 residents (Residents #9, #11, #51, #53, #58 and #167) reviewed for infection control. 1. The facility failed to ensure Resident #9 who had an indwelling suprapubic catheter (a tube surgically inserted through the lower abdomen into the bladder to drain urine) and an unstageable pressure ulcer/injury to the left heel (a wound caused by pressure from a surface) had Enhanced Barrier Precautions signage and PPE set up before entering his room and failed to ensure staff wore PPE during high contact resident care activities. 2. The facility failed to ensure CNA A and CNA B followed enhanced barrier precautions while providing incontinent care to Resident #11, who had a gastrostomy tube (G-tube) (a small flexible…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-04 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were evaluated for services for 2 of 5 residents (Residents #6 and #19) reviewed for PASRR. The facility failed to ensure the accuracy of the PASRR Level 1 (P1) screen for Resident #6 and Resident #19. This failure could place residents who had a mental illness at risk of not receiving individualized specialized services to meet their needs. 1. Record review of the June 2025 Physician Order indicated Resident #6 was an [AGE] year-old female who was admitted on [DATE]. Her diagnoses included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life); bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs); and adjustment insomnia (sleep disorder where people have difficulty sleeping). She had orders, dated 09/09/2024, to receive…

    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 · D2025-06-04 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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 medications (is a medication used: without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 1 of 5 residents (Resident #6) reviewed for unnecessary medications. * The facility failed to ensure Resident #6 had an appropriate diagnosis on entered orders for her Seroquel (antipsychotic). This failure could place residents at risk for unintended, harmful events attributed to the use of a medication without the appropriate indication. Findings included: Record review of Physician Orders for June 2025 indicated Resident #6 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life); bipolar disorder (mental disorder…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-04 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs were stored in a locked compartments under proper temperature controls, and only permitted authorized personnel to have access to the keys for 1 of 20 resident (Resident #29) reviewed for storage and labeling of medications. The facility failed to ensure Resident #29 did not have over the counter medications, Luden's cough drops, Neosporin and Equate hydrocortisone cream at the bedside. This failure could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications. The findings include: Record review of Resident #29's face-sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included chronic hepatic failure(liver failure), cirrhosis of liver(hardening of liver) and essential hypertension, Record review of Resident #29's consolidated…

    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 · F2024-05-21 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen reviewed for food and nutrition services. The facility failed to designate a person to serve as the dietary manager who met the required qualifications. The facility designated Dietary Supervisor did not have a dietary manager's certification or any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings include: Record review of the personnel file for the acting Dietary Supervisor indicated no documentation that she had completed the certified Dietary Manager course. During an interview on 05/19/24 at 8:45 a.m., the Dietary Supervisor said she had not completed or started the dietary manager classes. She said she was working as dietary supervisor until the facility could hire a certified dietary manager. During an interview on 05/20/24 at 10:45…

    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 · F2024-05-21 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the only kitchen reviewed for dietary services. The facility failed to ensure food items were properly labeled with product and expiration date in the refrigerators. These failures could place residents, who ate meals prepared in the kitchen, at risk for food borne illness. Findings included: During an observation and interview with the dietary supervisor on 05/19/2024 at 8:45 a.m. indicated the following: Refrigerator #1 contained *½ browning avocado in a gallon size bag with not labeled or dated. Refrigerator #2 contained *2 single serve sippy cups containing a white colored substance not labeled or dated; *1 single serve covered container with orange slices that was not labeled or dated; *a piece of ham (approximately 4 inches by 3-inches) covered with foil wrap and was not labeled or dated; and *a disposable Styrofoam serving dish containing sliced cucumbers not labeled or dated. The acting dietary supervisor said the sippy cups…

    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 · F2024-05-21 · tag F0836 — widespread
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility's governing body failed to operate and provide services in compliance with all applicable Federal, State and local laws, regulations, and codes for 1 of 1 facility reviewed for Social Worker (SW). The facility did not employ or contract a SW as required by state regulations. This failure could place residents at risk of administrative duties not being carried out attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Findings included: During an interview on 05/19/24 at 10:45 a.m., the Administrator said the facility did not currently did not have a SW. He said the SW quit about a month ago. He said they were actively looking for one. Record review of a Social Services Policy dated 01/01/24 indicated Policy: The facility will employ a full/part time Social Worker Record review of the Texas Administrative Code 554.703 (a)(2) indicated (2) A facility of 120 beds or less must employ or contract with a qualified social worker (or in lieu thereof, a social worker who is licensed by the…

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

    Administration Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · F2024-05-21 · tag F0944 — widespread
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program was completed for 17 of 17 employees (Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M) reviewed for training. The facility did not ensure QAPI training was completed by the Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring. Findings included: Record review of employee files indicated QAPI training was not done for the following staff: * Administrator, hire date 03/08/05; * Assistant Administrator, hire date 07/31/17; * DON, hire date 01/19/15; * ADON, hire date 05/27/09; * AD, hire date 10/06/97; * MD, hire date 07/01/04; * HS, hire date 02/05/14; * LVN D, hire date 02/08/22; * LVN E, hire…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-05-21 · tag F0946 — widespread
    Provide training in compliance and ethics.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure compliance and ethics training was completed for 17 of 17 employees (Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M) reviewed for training. The facility did not ensure compliance and ethics training was completed by the Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not completed compliance and ethics training: * Administrator, hire date 03/08/05; * Assistant Administrator, hire date 07/31/17; * DON, hire date 01/19/15; * ADON, hire date 05/27/09; * AD, hire date 10/06/97; * MD, hire date 07/01/04; * HS, hire date 02/05/14; * LVN D, hire date 02/08/22; * LVN E, hire date 05/03/12; * LVN F, hire date 08/07/23; * RN G, hire date 02/16/24; * CNA H, hire date…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-21 · tag F0940 — failed to train staff — pattern
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure individuals providing services under a contractual arrangement had trainings consistent with their expected roles and failed to keep records of these trainings for 4 of 4 contracted staff. (Dietician, PT, OT, and ST). The facility failed to ensure required trainings were provided for the dietician working in the dietary department at the facility under a contractual agreement. The facility failed to ensure required trainings were provided for PT, OT, and ST working in the therapy department at the facility under a contractual agreement. This failure could place residents at risk of being cared for by contracted staff who have been insufficiently trained to improve resident safety, create a more person-centered environment, and reduce the number of adverse events or other resident complications. Findings included: During an interview on 05/20/24 at 03:30 p.m. the HR said she did not know if there were files for the dietician and therapy staff. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she did 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-21 · tag F0941 — pattern
    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure employees received the required training effective communications mandatory training was completed for 11 of 17 employees (Administrator, Assistant Administrator, LVN F, RN G, AD, MD, HS, CNA K, CNA L, CNA M, and CNA N) reviewed for training. The facility did not ensure effective communication training was completed by LVN F, RN G, CNA L, CNA M, and CNA N during orientation. The facility did not ensure effective communication training was completed by the Administrator, Assistant Administrator, AD, MD, HS, and CNA K annually. These failures could place residents at risk of miscommunication and social isolation due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not completed effective communications training during orientation: * LVN F, hire date 08/07/23; * RN G, hire date 02/16/24; * CNA L, hire date 09/07/23; * CNA M, hire date 01/24/24; and * CNA N, hire date08/14/23. Record review of employee files indicated the following staff had not completed…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-21 · tag F0942 — pattern
    Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the rights of the resident and responsibilities of the facility were completed for 5 of 17 employees (DON, LVN D, LVN F, CNA K, and CNA N) reviewed for training. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by LVN F and CNA N during orientation. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by DON, LVN D, and CNA K annually. These failures could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of employee files indicated the following staff had not completed resident rights and responsibilities of the facility training during orientation: * LVN F, hire date 08/07/23; and * CNA N, hire date 08/14/23. Record review of employee files indicated the following staff had not completed resident rights and responsibilities of the facility training annually: * DON, hire date 01/19/15; * LVN D, hire date 02/08/22;…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-21 · tag F0943 — pattern
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure employees received the required training on Abuse, Neglect, and Exploitation (ANE) for 2 of 11 (DON, LVN F) and dementia management for 1 of 11 employees (LVN F) reviewed for training. The facility did not ensure ANE and dementia management training was completed by the LVN F during orientation. The facility did not ensure ANE training was completed by the DON annually. The facility did not ensure ANE training was completed by the HS annually. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents. Findings included: Record review of the employee files indicated: * LVN F, hire date 08/07/23, had not completed ANE and dementia management training during orientation; and * DON, hire date 001/19/15, last completed ANE training on 01/31/23. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-21 · tag F0945 — failed to train staff on abuse prevention — pattern
    Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure standards, policies, and procedures for an infection prevention and control program was completed for 2 of 17 staff (LVN F and MD) reviewed for training. The facility did not ensure infection prevention and control training was completed by LVN F during orientation. The facility did not ensure infection prevention and control training was completed by the MD annually. These failures could place residents at risk of illness due to lack of staff training. Findings included: Record review of employee files indicated: * LVN F, hire date 08/07/23, had not completed infection prevention and control training during orientation; and * MD, hire date 07/01/04, had not completed infection prevention and control training annually. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated all trainings were done in the computer except for the skills competencies she conducted on…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-21 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure CNAs completed Abuse, Neglect, and Exploitation (ANE) and dementia management trainings for 2 of 6 CNAs (CNA K and CNA N) reviewed for training. The facility did not ensure ANE and dementia management trainings were completed by CNA N during orientation. The facility did not ensure ANE and dementia management trainings were completed by CNA K annually. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents. Findings included: Record review of employee files indicated CNA N, hire date 12/07/23, had not completed ANE and dementia management trainings during orientation. Record review of employee files indicated CNA K, hire date 10/25/21, hot not completed ANE and dementia management annual trainings. During an interview on 05/21/24 at 01:21 p.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-21 · tag F0949 — failed to train staff on dementia and abuse — pattern
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure training on behavioral health was completed for 11 of 17 employees (Administrator, Assistant Administrator, AD, MD, HS, LVN F, RN G, CNA K, CNA L, CNA M and CNA N) reviewed for training. The facility did not ensure behavioral health training was completed by LVN F, RN G, CNA L, CNA M and CNA N during orientation. The facility did not ensure behavioral health training was completed by the Administrator, Assistant Administrator, AD, MD, HS, and CNA K annually. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not behavioral health training during orientation: * LVN F, hire date 08/07/23; * RN G, hire date 02/16/24; * CNA L, hire date 09/07/23, * CNA M, hire date 01/24/24; and * CNA N, hire date 08/14/23. Record review of employee files indicated the following staff had not completed…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-21 · tag F0641 — isolated
    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 observation, interview, and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 20 residents reviewed for assessments. (Resident #24). The facility failed to complete an accurate resident assessment for Resident #24. Resident #24's resident assessment did not indicate she received special treatments, procedures, and programs of oxygen therapy. This failure could place residents at risk of not having individual needs met and a decreased quality of life. Findings included: Record review of a face sheet dated 05/19/24 indicated Resident #24 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included Chronic Pulmonary Disease (COPD- a chronic inflammatory lung disease that causes obstructive airflow from the lungs) and dependence on supplemental oxygen (oxygen therapy helps people with lung diseases or breathing problems get the oxygen their bodies need to function). Record review of physician orders for May 2024 indicated Resident #24 had an order…

    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 · E2023-03-22 · 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 develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 3 of 19 residents reviewed for care plans. (Residents #15, #65 and #72) *The facility failed to care plan Resident #15 as having a suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder. The tube is inserted into the bladder through a cut in the stomach , a few inches below the navel. *The facility failed to care plan Resident #65 for the use of Duloxetine (a medication used to treat depression). *The facility failed to care plan Resident #72 for the use of Eliquis (a medication used to prevent blood clots) and his use of an AutoPAP (a continuous positive airway pressure device that delivers effective sleep therapy catered to the individual's immediate…

    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 · E2023-03-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 3 of 19 residents reviewed for respiratory care and services. (Resident #s 14, 30, and 76) * The facility did not provide Resident #14's oxygen concentrator with a clean filter. The filter was covered with a thick layer of gray powdery substance. *The facility failed to administer the correct dose of oxygen to Resident #30. *The facility failed to administer the correct dose of oxygen to Resident #76. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. admission report indicated Resident #14 was a female [AGE] years old, admitted on [DATE] with diagnosis of COPD (Chronic Obstructive Pulmonary Disease) [chronic lung…

    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
  • No harm found · C2023-03-22 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 post information daily regarding registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides. The facility failed to post the total number of hours worked for licensed nurses and certified nurse aides with the daily census. This failure could place residents at risk of being unaware of the facility's daily staffing requirements. Findings include: During an observation on 3/20/23 at 9:00 a.m., there was not a Direct care daily staffing sheet posted in the building. During an observation on 3/21/23 at 10:30 a.m., there was not a Direct care daily staffing sheet posted in the building. During an observation on 3/22/23 at 12:45 p.m., there was not a Direct care daily staffing sheet posted in the building. During an interview on 3/22/23 at 12:50 p.m., the ADON said the Direct care daily staffing sheet was not posted and had not been posted in a very long time. During an interview on 3/22/23 at 1:23 p.m., the ADON said she was responsible for posting the Direct care daily…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
BURMONT, INC.Organization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 04/01/2025
LIBERTY COMPLETE, LPOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 04/01/2025
ARNOLD, CONRADIndividual5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 04/01/2025
MONTGOMERY, DEBRAHIndividual5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 04/01/2025
MONTGOMERY, RAYMONDIndividual5% OR GREATER MORTGAGE INTERESTsince 04/01/2025
MURRELL, EDWARDIndividualCORPORATE OFFICERsince 04/01/2025
MAGNOLIA PLACE HEALTH CARE L L POrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/04/2025
ARNOLD, JASONIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
CALLENS, DONIndividualADP OF THE SNFsince 04/01/2025
OTT, ADAMIndividualADP OF THE SNFsince 04/01/2025

CMS files one row per role, so the 15 rows in the source record cover these 10 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.

3 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.

$5.7M
Net patient revenuemost recent cost report
-3.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 72%Medicare 10%Other / private 18%

About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$211per resident / day
operating cost
$6,408per month
≈ monthly operating cost
$203per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676011. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-04, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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